Neurologic System Paper.
Neurologic System Paper.
With your lab partner assuming the role of a client, conduct a focused history and examination. Your “student client” may role-play a client with a particular neurologic symptom.
History Date: Name:
Gender: M F
Age: Race: LMP:
Occupation:
Source of Data:
Immunizations:
Allergies/Reactions:
Presenting Problem (check all that apply):
Headaches Dizziness Seizures Loss of consciousness
Changes in movement
Changes in sensation
Difficulty swallowing
Difficulty communicating
Other:______
Symptom Analysis of Presenting Problem (location, quality, quantity, chronology, setting, associated manifestations, aggravating and alleviating factors) Present Health Status (include medications, dose, and frequency) Past Medical and Surgical History (include description and dates) Family History
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Chapter 16 Neurologic System Page 2
Examination
Examination Technique Findings (document findings below)
Routine Assessment ASSESS Mental Status.
o Level of consciousness o Speech for articulation and voice
quality and conversation of verbal communication
NOTICE cranial nerve functions. o CN I (olfactory)—smell o CN II (optic nerve)—ability to
move in environment and see chair to sit
o CN III (oculomotor), IV (trochlear), VI (abducens)—eye movement
o CN V (trigeminal)—eye blink o CN VII (facial)—face is
symmetric during talking or smiling
o CN VIII (acoustic)—ability to hear
o CN IX (glossopharyngeal), CN X (vagus)—swallowing and ability to handle saliva
o CN X (vagus)—guttural speech sounds
o CN XI (spinal accessory)—shrug shoulders or turn head
OBSERVE gait for balance and symmetry.
EVALUATE extremities for muscle strength.
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 16 Neurologic System Page 3
Examination Technique Findings (document findings below)
Special Circumstances and Advanced Practice ASSESS individual cranial nerves.
o TEST nose for smell. o TEST eyes for visual acuity. o TEST eyes for peripheral vision. o OBSERVE eyes for extraocular
muscle movement. o OBSERVE eyes for papillary size,
shape, equality, constriction, and accommodation.
o EVALUATE face for movement and sensation.
o TEST ears for hearing. o TEST tongue for taste. o INSPECT orophyarynx for gag
reflex and movement of soft palate.
o TEST tongue for movement, symmetry, strength, and absence of tumors; test for muscle strength.
o TEST shoulders and neck muscles for strength and movement.
TEST cerebellar function for balance and coordination.
o TEST for balance. – Romberg test – With eyes closed, stand on one
foot, then the other – Heel-to-toe walking – Hop on one foot, then the other – Deep knee bends – Walk on toes, then on heels
o EVALUATE upper extremity. – Alternately tap hands to thighs – With eyes closed and
outstretched arms, touch finger to own nose
– Touch each finger to thumb in rapid sequence
– Rapidly move finger between nose and nurse’s finger
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 16 Neurologic System Page 4
Neurologic System Paper.
Examination Technique Findings (document findings below)
o EVALUATE lower extremity. – Lying supine, slide heel down
opposite shin ASSESS peripheral nerves.
o ASSESS for sensation—close eyes and test for sensation identification on upper and lower extremities.
o ASSESS sharp and dull sensation. o ASSESS peripheral sensation with
monofilament (advanced practice). o ASSESS vibratory sense using
tuning fork (advanced practice). o ASSESS kinesthetic sensation.
(advanced practice).
o TEST stereognosis (advanced practice).
o TEST two-point discrimination. (advanced practice).
o EVALUATE graphesthesia (advanced practice).
EVALUATE extremities for deep tendon reflexes.
o Triceps reflex o Biceps reflex o Brachioradial reflex o Patellar reflex o Archilles tendon
EVALUATE plantar reflex (advanced practice).
EVALUATE ankle clonus (advanced practice).
EVALUATE for superficial reflexes (abdominal).
Neurologic System Paper.
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Chapter 16 Neurologic System Page 5
Nursing Diagnoses and Collaborative Problems Based on the subjective and objective data collected above, identify applicable nursing diagnoses and collaborative problems.
Nursing Diagnoses Collaborative Problems
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier I