Health Assessment
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NeurologicSystemconverted3.pdf
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Student Laboratory Guide
Chapter 16: Neurologic System
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:
15/04/20
21
Name: Duncan Junior Gender:
M F
Age: 60 Race: black LMP:
16/03/2021
Occupation: Human Resource
Manager at Apple Company
Source of Data: Medical records and laboratory tests
Immunizations: Influenza Allergies/Reactions: Itchy skin
Presenting Problem (check all that apply):
✓Headaches ✓ Dizziness Seizures Loss of consciousness
Changes in
movement
Other:
fainting
during an
episode and
light headed.
Changes in
sensation
Difficulty
swallowing
Difficulty
communicating
Symptom Analysis of Presenting Problem (location, quality, quantity, chronology, setting, associated manifestations, aggravating and alleviating factors)
Yesterday Evening 12/04/2020 (7pm)
L: Dizziness that is felt throughout the body
D: constant all day
C: Weakness though out the body
A: Physical exercise increases the pain.
R: light headedness and faintness
T: None
S: Cannot carry out day to day activities during an episode.
Present Health Status (include medications, dose, and frequency)
The patient has type 2 diabetes therefore she takes Metformin 500mg twice in a day. She was
diagnosed with type 2 diabetes when she was 30 years old.
Past Medical and Surgical History (include description and dates)
Type 2 diabetes has greatly affected the nerves.
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Family History
The patient’s mother died due to diabetes.
Chapter 16 Neurologic System Page 2
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
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.
The patient can answer all the questions and
communicate effectively. Her voice is mellow and
calm.
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,
The Romberg test shows that the patient had an unaffected balance while heel walking and toe walking. The eyelid test shows that the patient can respond to light.
Chapter 16 Neurologic System Page 4
2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 16 Neurologic System Page 4
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
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).
The reflexes observed in biceps, triceps, plantar,
brachioradialis and patellar. The patient demonstrated
point to point exercise fully. The patient
demonstrated rapid movement of the lower as well as
the upper extremities.
Chapter 16 Neurologic System Page 5
Mosby items and derived items © 2009, 2005, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
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
