com’s Assessment Series: Focused Neurological Assessment

Presented by: RN.com 12400 High Bluff Drive San Diego, CA 92130 This course has been awarded two (2.0) contact hours. This course expires on October 5, 2014.

Copyright © 2004 by RN.com. All Rights Reserved. Reproduction and distribution of these materials are prohibited without the express written authorization of RN.com.
First Published: October 5, 2004 Revised:October 5, 2011

Material Protected by Copyright

She has been an educator. MSN has over 21 years staff nurse and charge nurse experience with medical/surgical. Conflict of Interest is defined as circumstances a conflict of interest that an individual may have. C-FNP.com strives to keep its content fair and unbiased. …Lori Constantine MSN. and reviewers have no conflicts of interest in relation to this course. and her Master of Science in Nursing through University of Phoenix in 2005. which could possibly affect Education content about products or services of a commercial interest with which he/she has a financial relationship. Kim is certified in Neonatal Intensive Care Nursing and is currently pursuing her PhD in Nursing. If there is a disruption to any of these processes. The use of trade names does not indicate any preference of one trade named agent or company over another. This course will discuss specific neurological history questions and exam techniques for your adult patient. original course author. Kim graduated with a nursing diploma from Foothills Hospital School of Nursing in Calgary. the whole body suffers. BN. The author(s). Material Protected by Copyright . and use of simulation.Disclaimer RN. Acknowledgements RN. Additionally. instructor. Kim’s current role in professional development includes nursing peer review and advancement. throughout the course. There is no commercial support being used for this course. RNC-NIC.Kim Maryniak. Participants are advised that the accredited status of RN. You are encouraged to consult with physicians and pharmacists about all medication issues for your patients. The information on medications contained in this course is not meant to be prescriptive or all-encompassing. Note: All dosages given are for adults unless otherwise stated. and nursing director.. Her instructor experience includes med/surg nursing and physical assessment. Purpose and Objectives The fundamental processes of the brain and nervous system are key to understanding why nurses perform a focused neurological assessment. teaching. psychiatry. She achieved her Bachelor in Nursing through Athabasca University. pediatrics.. There is no "off label" usage of drugs or products discussed in this course.com acknowledges the valuable contributions of… . You may find that both generic and trade names are used in courses produced by RN. She is active in the National Association of Neonatal Nurses and American Nurses Association. Alberta in 2000. Trade names are provided to enhance recognition of agents described in the course. and auscultation will be highlighted.com.com does not imply endorsement by the provider or ANCC of any commercial products mentioned in this course. planning committee. RN. palpation. you will learn how alterations in your neurological assessment findings could indicate potential nervous system abnormalities. Physical exam techniques such as inspection. Alberta in 1989. and neonatal intensive care. percussion.

Specific signs and symptoms manifested by your patient are associated with specific areas of the brain. It allows for baseline neurological status to be ascertained at the beginning of each shift. When reporting off. baseline neurological examination on any patient that has verbalized neurological concerns in their history. Each side of the body should be compared with the other side to detect any abnormalities. symmetrical fashion. Their complaints of pain are mentioned more in association with an extremity. auscultation. 2. or head assessment. This way. If they are not conscious. It may not be necessary to perform the entire neurological exam on a patient with no suspicion of neurological disorders. Most patients do not complain of pain in the neurological history. you can ask the patient the following history questions. Recheck the neuro exam at periodic intervals with any patient that has a neurological deficit (Berman. Describe abnormal neurological assessment findings associated with inspection. precipitating factors. Do you have frequent or severe headaches? (when. This ensures the subjectiveness of your exam is not misinterpreted by the next examiner. Material Protected by Copyright .After successful completion of this course. Integrate the steps of the neurological history with the steps taken during the complete physical examination. 2008. Jarvis. how often) Pain is a neurological phenomenon or symptom. where. Kozier & Erb. The past medical records may also provide some answers to the following questions as well. You must also recognize when further neurological injury is manifesting. Introduction The neurological history and exam allows the examiner to pinpoint various areas of the brain or nervous system that may be dysfunctional. the participant will be able to: 1. percussion. Nurses observe for signs and symptoms that may be abnormal and link them to general areas of the nervous system that may be causing the disturbance. loss of consciousness) This question may give you clues to underlying neurological damage that may change your patient’s baseline. it is wise to perform a brief exam with the oncoming nurse at the bedside. and notify the physician for a change in plans for the patient. ask the following: • • Do you have any past history of head injury? (location. History Taking: The Adult Patient When your adult patient is conscious. Outline a systematic approach to neurological assessment. and whether onset is gradual or sudden. Also. History Taking: The Adult Patient Inquire if there has been any history of dizziness or vertigo? Clarify frequency. When assessing the nervous system with your adult patient. intervene appropriately. you will be certain that all areas are assessed. Snyder. and palpation. Discuss history questions which will help you focus your neurological assessment. sometimes a family member or friend can provide some of this information. when a change in neurological function is experienced by the patient it is more easily identified. 2008). back. History & Examination The exam and history should be in an orderly. You should perform a complete. 3.

a sudden loss of consciousness usually due to a lack of cerebral blood flow. Inquire about the patient's past neurologic history: Occurrence of a cerebral vascular accident [CVA]. precipitating factors. Inquire about the patient's stress or presence of any mental health disorders: Anxiety or stress disorder. Vertigo is experienced as a rotational spinning. Any abnormal sensations such as numbness or tingling may be referred to as paresthesia. neurologic infections. organic solvents. or known mental health disorders should precipitate a further assessment. the patient will describe an aura. and alcohol may all manifest in neurological symptoms (Jarvis. Muscle tone and strength may be affected by both peripheral and central abnormalities. which may be a warning signal for impending stroke. 2008. course and duration. or congenital disorders. frequency. 2000. Often. including a mini mental status exam. visual. Specific neurological infections could include meningitis and encephalitis. These questions may clue you in to potential transient ischemic attacks (TIAs). History of excessive stress. or motor warning of the impending seizure. If the patient answers yes to this question. spinal cord injury. length and nature of exposure. It is usually due to neurological disorder or an inner ear disturbance. then ask when it was first noticed and how long did it last. Strub & Black.• • Syncope (fainting) is a sudden lack of strength. Inquire about difficulty with speech: Forming words or saying what was intended. D’Amato. mania. depression. or excessive salivation. 2008). post-ictal phase. Seizures typically occur in disorders such as epilepsy. motor activity associated with. medications. Inquire about seizures? (when did they start. & Hartlage. associated signs. an auditory. drugs. Material Protected by Copyright . Inquire about environmental or occupational hazards: Type. Exposure to insecticides. Inquire about coordination difficulties: Ask the patient to describe in detail. lead. or schizophrenia. History Taking: The Adult Patient Inquire about difficulty in swallowing: solids or liquids. Difficulty in swallowing may indicate a possible abnormality with cranial nerves IX and X. and coping strategies). anxiety. History Taking: The Adult Patient Inquire about numbness or tingling: Ask the patient to describe in detail.

and Elderly Patients Additional history questions you may wish to ask regarding your infant.Infant. begin by assessing mental status: The mental status portion of the examination is a series of detailed but simple questions designed to test cognitive ability including: • The patient's awareness and responsiveness to the environment Material Protected by Copyright . It may not be necessary to perform the entire neuro exam on a patient with no suspicion of neuro disorders. Evaluation of Mental Status When performing the complete neuro exam. Jarvis. pediatric. or aging patients are listed in the table below: Additional History for Infants Additional History for Children Additional History for Elderly Patients Any problems with dizziness? If so when does it occur? Does the child have any balance problems? Any Did the mother have any unexplained falling? health problems during Muscle weakness? pregnancy? Difficulty getting up and down stairs? Tell me about the baby’s birth? Premature or term? Birth weight? Apnea? APGAR scores? Does the child have any seizures? Describe the circumstances around which they occurred. Did motor and developmental milestones occur during the appropriate age range? Any decrease in memory or change in mental functioning? Any congenital defects? Any tremors in your hands or face? Has your child had any Are sucking and environmental exposure swallowing coordinated? to lead? Any sudden vision changes or sudden blindness? Any sudden weakness on Does baby turn his head Any learning problems in one side of the body and toward touch? school? not the other? Does baby startle with a loud noise? (Jarvis. 2008) Any family history of neurological disorders? Ever experience loss of consciousness? The Complete Neurological Exam Integrate the steps of the neurological history with the steps taken during the complete examination. 2008). 2008. Recheck the neuro exam at periodic intervals with any patient that has a neuro deficit (Berman. You should perform a complete baseline neurological examination on any patient that has verbalized neuro concerns in their history. Pediatric. Snyder. Kozier & Erb.

light touch. slow. If not. injured and bandaged right hand). agitated or lethargic? Does the patient need minor/considerable reinforcement and soothing? Is the patient's behavior oppositional/resistant. Behavior & Speech Gait and Motor Coordination: Movement: Is movement awkward. Additionally. candid and cooperative. alert. appearance and general behavior Assessment of mood. pain? Verbal response to your questions should also be noted. rigid. Presenting Appearance: Overall appearance including apparent age. any physical deformities (hearing impaired. or is it pressured. accented? Describe the enunciation quality. and you still feel the patient’s neurological status is impaired. staggering. but should establish if the patient is oriented to person. negative. content of thought. place. depressive. assaultive. quiet or impoverished. irritable. Memory & Recall Eye Contact: Does the patient make eye contact or avoid it? Comprehension: Does the patient appear to understand conversation and instructions? Can the Material Protected by Copyright . what does it take to get them alert: Calling their name. and person. exhibitionistic. and orientation with reference to time. weather and situation (physician visit) and the purpose of accessories like glasses or a cane. Most healthcare professionals will not perform a detailed mental status exam. healthy. vigorous touch. angry. Mental Status: Eye Contact. sullen. such as dementia. unconcerned. determine if the patient is alert. place. frightened. evasive. submissive. Mental Status: Appearance & Hygiene Healthcare professionals should know that many neurological diseases. or exhibits subdued mistrust and hostility or excessive shyness? Speech: Is the patient's speech delivered at a normal rate and volume. and time. indifferent. and specific personality features. height and weight (average. Mental Status: Co-ordination. open and friendly. Basic Grooming and Hygiene: Appropriateness of attire for age. defensive.• • Assessment of the senses. stocky. anxious. shuffling. completion of a full mental status exam may be warranted. tempo and whether it is loud. or trembling with intentional movement or at rest? Is movement speed normal? Is posture slouched or erect? Are there any inappropriate mannerisms or gestures? Behavior: Is the patient's behavior distant. cause changes in intellectual status or emotional responsiveness. Comprehension. petite). ethnicity. If other parts of the neurological exam are normal. seductive.

ideas of reference. obsessions. and if they expected the outcome to be what is was. time. An example of this would be: What are two different meanings for the word "right" "bit" or "left?" Material Protected by Copyright . or displaying signs of visual. which are denied except for times associated with the use of substances or medications? Judgment and Insight: Is judgment and insight present? This would be evident in explanations of what they did.. For example. olfactory or auditory hallucinations during testing. or reports experiences of depersonalization. Establish alertness by evaluating for sleepiness. Or ask the patient to name the days of the week or months of the year in reverse order. or spell the word "world" or their own last name. magical thinking. grandiosity. above average.patient express feelings. Attention & Thought Processes Orientation: Check orientation to person.") or similarities in thought. what happened. Mental Status: Hallucinations. or recite the ABC's backwards.. Judgment & Intellect Hallucinations and Delusions: Is there evidence of hallucinations or delusions? Is the patient absent on questioning. flight of ideas. presidents and your name. Thought Processes: Ask the patient to recall the plot of a favorite movie or book logically. To test digit span. confabulations. zebra. request that the patient count backwards from 100 to 50 in multiples of 7's or 3's). or below average based on answers to questions like "name last four presidents. Intellectual Ability: Assess if intellect is average.. place. how two words are alike or different. perseveration. If they can't. disinterest or distractibility. Cadillac. perseveration (the tendency of a memory or thought to persist) or mumbling? Recall and Memory: Can the patient recall three random words (e. provide circumstantial and tangential responses. illogical thinking. alertness. Concentration and Attention: Evaluate based on Digit Span (recall of numbers) and attention to your questions. delusions. and then again five minutes later (five minutes is how long it takes for information to move from short-term to long term memory). exhibit anomia (difficuly finding words) or misuse words in a low-vocabulary-skills way or misuse of words in a bizarrethinking-processes way? Is there evidence of echolalia (repetition of other people's words). or shows loose associations." "who is the governor of the state?" Mental Status: Abstraction Skills. Mood & Affect Abstraction Skills: Are based on proverbs and sayings ("What do people mean when they say. identify if line of reasoning is difficult to follow. and giving both definitions for word.g. you can prompt them? Can the patient recall your name after 30 minutes? Mental Status: Orientation. and purple) immediately after two rehearsals.

angry. and muscle diseases. inappropriate or labile emotions. or is the patient unaware? Impulsivity: Is it low medium. or tenuous and easily upset? Facial and Emotional Expressions: Does the patient appear to be relaxed. flat. age. which is the plan or intent to kill another person. irritable. Sensory components transmit nerve impulses from sensory organs to the brain. and gender? Atrophy is abnormally small muscles with a wasted appearance. injury. Material Protected by Copyright . verbally threatened examiner. happy. Some nerves have only a sensory component. sad. low. difficult to establish. Most often. uncertain or affected by substance use? Response to Failure on Test Items: Does this make the patient frustrated. This can occur with disuse. day-dreamy. distrustful / suspicious. a neurological problem is detected through the assessment of these nerves. some only a motor component. The cranial nerves are composed of twelve pairs of nerves that stem from the nervous tissue of the brain. Affect: Is how the patient feels or felt at any given moment: Can include a wide range of emotions like restricted. sad. high. or tearful when discussing something? Is the patient anxious? If anxiety is present. Mental Status: Additional Clues Assess the patient for addition clues to mental stability. tense. melancholic. alert. Also consider if the affect is consistent with the content of the conversation and facial expressions. cried while discussing recent happy event and unable to explain why). The motor components of cranial nerves transmit nerve impulses from the brain to target tissue outside of the brain. high. how does the patient handle this emotion? Suicidal and Homicidal Ideation: Suicide ideation is a plan or intent to kill oneself. Does your patient have appropriate size muscles for body type. affected by substance use? Twelve Cranial Nerves The cranial nerves arise directly from the central nervous system. motor neuron diseases. initially difficult but easier over time. compared to homicidal ideation. despondent. A summary of the functions of the cranial nerves is listed in the table by clicking on the more information button below. for example: Pessimistic or optimistic) as well as inappropriate signs (began dancing in the office. Risk for Violence: Is the patient's risk for violence fair. blunted. anxious or angry. elevated. Inspection & Palpation: Muscle Size Begin the inspection and palpation of the motor system by examining muscle size. euphoric.Mood: Inquire how the patient feels most days: Happy. anxious or obsessed. depressed. and some both. including assessment of: Rapport : How difficult is it to establish rapport with the patient: Is it easy to establish.

using a 0 – 5 scale. 2008. Kozier & Erb.Hypertrophy (increased size) occurs with athletes and body builders. and fasciculations (involuntary contraction of a muscle) are all examples of abnormal involuntary movements you may note on exam (Berman. abnormalities in muscle tone will become more evident. 2008). push wrist down Squeeze examiners finger Pull fingers apart Squeeze fingers together Inspection & Palpation of Muscle Tone When testing muscle strength in the legs ask your patient to do the following against resistance: Lift legs up Push legs down Pull legs apart Push legs together Pull lower leg towards upper leg Push lower leg away from upper leg Push feet away from legs Pull feet towards legs When testing muscle strength. Abnormal muscle tone findings can include: • • • Limited range of motion Pain on motion Decreased resistance (flaccidity) or increased resistance (rigidity). When testing muscle strength in the arms ask your patient to do the following against resistance: Lift arms away from side Push arms towards side Pull forearm towards upper arm Push forearm away from upper arm Lift wrist up. tremors. Snyder. It is characterized by increased size and strength of muscles. Jarvis. with 0 = no movement and 5 = strong muscle strength. Inspection& Palpation of Muscle Strength Test muscle strength against a resistance. Muscle strength should be equal bilaterally. Material Protected by Copyright . or spasticity Involuntary Movements Tics.

so if they begin to fall. dressing. lower extremity coordination may be impaired. The cerebellum controls the property of movements. dragging or slapping of foot. rapid alternating movements are assessed. have your patient touch their nose with their index finger of each hand with eyes shut.forwards and backwards. have the patient run the heel down the shin to the ankle. fine voluntary movements as required in writing. Patients should be able to do this without missing the mark. The Finger to Finger Test: To perform. and skilled movements. The Finger to Nose Test: To perform. Test each leg. as you move your index finger in the space around them. have your patient touch the heel of one foot to the knee of the opposite leg. have the patient touch your index finger with their index finger. Checking cerebellar functioning includes testing balance. wide base of support. such as speed. Abnormal findings might be lack of coordination. and trajectory. or slow. acceleration. Material Protected by Copyright . and presence of ataxia (lack of co-ordination).test both sides. have the patient stand with feet together and arms extended to the front.Cerebellar Function Although the cerebellum does not initiate movements. alternating palm up and then palm down . The Heel to Shin Test: While standing. using a variety of quick tests: • The Alternating Palm Slap Test: Have your patient rapidly slap one hand on the palm of the other. clumsy movements. While maintaining this contact. Stay next to the patient when they are performing this test in particular. including maintaining proper posture and balance. Your patient should be able to maintain their balance. eating. and playing musical instruments. Patients should be able to do this without missing the mark. unequal steps. Have your patient close his eyes while checking sensory perception. and higher cortical discrimination. lack of arm swing. and smooth tracking movements of the eyes. Assessment of Cerebellar Function: Rapid Alternating Movements To further assess cerebellar function. coordination. sensory tracts. you can catch them. Balance should be maintained. Assessment of Cerebellar Function: Gait & Romberg's Test Gait Have the patient walk heel to toe in a straight line . Assess for abnormalities such as stiff posture. Romberg’s Test With eyes closed. it interrelates with many brainstem structures in executing various movements. staggering. palms up. • • • Assessing The Sensory System Testing the sensory system checks the intactness of peripheral nerves. walking and running. If your patient misses the mark.

temperature. The patient should be able to tell you which way there toes are moving. and light touch. Position Position or kinesthesia is tested by having the patient close their eyes and move their big toe up and down. and analgesia. anesthesia. Stereognosis tests the Material Protected by Copyright . If these areas are normal. Light touch With a cotton ball or soft side of a Q-tip. Assessing The Posterior Column Tract Assessing the posterior column tract may identify lesions of the sensory cortex or vertebral column. Snyder. 2008. hyperalgesia. Abnormal responses include hypesthesia. and hyperesthesia. Jarvis. Kozier & Erb. 2008). Abnormal findings would include hypalgesia.Light Touch Can your patient feel light touch equally on both sides of the body? Sharp/Dull Can your patient distinguish between a sharp or dull object on both sides of the body? Hot/Cold Can your patient distinguish between a hot or cold object on both sides of the body? (Berman. touch the patient’s body bilaterally with their eyes closed. then you may assume the proximal areas are also normal. Ask them to indicate when you have touched them. Temperature Temperature should be tested only if pain test is normal. Presence of Pain Pain can be tested by a simple pin prick with the patient’s eyes closed. Hot and cold objects may be placed on the patient’s skin at various locations bilaterally to test for temperature sensation. Vibration Test the patient’s ability to feel vibrations by placing a tuning fork over various boney locations on the patient’s toes and feet. Assessing The Posterior Column Tract Tactile discrimination Tactile discrimination tests the discrimination ability of the sensory cortex. Assessing The Spinothalmic Tract Checking the spinothalmic tract tests your patient’s ability to sense pain.

the muscle fibers contract. when a specific area of the muscle tendon is tapped with a soft rubber hammer. Kozier & Erb. Reflexes & Spinal Nerve Roots The main spinal nerve roots involved in testing the deep tendon reflexes are summarized in the following table: Reflex Biceps Brachioradialis Triceps Patellar Achilles Tendon Main Spinal Nerve Roots Involved C5. or spinal cord injuries. have the patient grit their teeth then try to elicit the reflex again. Strike the reflex hammer across the selected tendon with a moderate tap. 2008. clonus is sometimes seen. Snyder. An increase in the distance it normally takes to identify two distinct pricks occurs with sensory cortex lesions (Berman. For example. Or you may have them clench their fists together when checking lower extremity reflexes. metabolic factors such as thyroid dysfunction or electrolyte abnormalities. The limbs should be in a relaxed and symmetric position. diseases of the pyramidal tract.C6 C6 C7 L4 S1 Check the deep tendon reflexes with a reflex hammer to stretch the muscle and tendon. Deep tendon reflexes can be influenced by age.patient’s ability to recognize objects by feeling them. Checking Reflexes Reflexes are involuntary actions in response to a stimulus sent to the central nervous system. They should be able to identify that object by feel only. a spoon. Two point discrimination Two point discrimination tests the brain’s ability to detect two distinct pin pricks on the skin. Jarvis. or other common object in your patient’s hand. You can place car keys. Normally. If you cannot elicit a reflex. Abnormal responses may indicate injury to the nervous system pathways that produce the deep tendon reflex. 2008). Stretch or Deep Tendon Reflexes Deep tendon reflexes. you can sometimes bring it out by certain reinforcement procedures. Rating Deep Tendon Reflexes When reflexes are very brisk. This is a repetitive vibratory contraction of the muscle that occurs in response to muscle and tendon stretch. also known as muscle stretch reflexes. Material Protected by Copyright . and anxiety level of the patient. a pencil. Graphesthesia is the ability to “read” a number “written” in your palm. are reflexes elicited in response to stimuli to tendons. Alterations in reflexes are often the first sign of neurological dysfunction such as upper motor neuron disease.

vigorous touch. Jarvis.Deep tendon reflexes are often rated according to the following scale: Rating Reflex Response 0 1+ 2+ 3+ 4+ 5+ Absent reflex Race. Presence of primitive reflexes in adults is often a sign of frontal lobe lesions. what does it take to get them alert . light touch. Snyder.do they know why they are there? Is your patient alert? If not. 2+. or are rated as 0. Kozier & Erb. or seen only with reinforcement Normal Brisk Non-sustained clonus (i. This exam is also useful for your inpatient with a head injury or systemic disease process that may be manifesting as a neuro symptom. Reflexes that are asymmetric. or 3+. elicits elevation of testes. Superficial Reflexes The following superficial reflexes are considered normal in adults.. When performing this abbreviated exam. or there is a large difference between the arms and legs. Lower Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. Cremasteric: Stroke inner thigh. and time? What about event.calling their name. pain? Are your patient’s responses to questions appropriate? Is speech intelligible? Material Protected by Copyright . Absence of superficial reflexes or unilateral suppression of superficial reflexes often results from upper motor lesions subsequent to a stroke.does your patient have pain? Use a rating scale. repetitive vibratory movements) Sustained clonus Deep tendon reflexes are considered normal if they are 1+. 4+. Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. 2008. Level of Consciousness (Monitors for signs of increasing intracranial pressure) Is your patient oriented to person. or 5+ abnormal (Berman. carefully evaluate the following: Vital Signs Is there a change in vital signs from patient’s baseline? Pain . place.e. 2008). The Neurological Recheck Exam Perform the neurological recheck exam at periodic intervals with any patient that has a neuro deficit.

As the plan of care is being carried out. Conclusion Integrating the neurological health history and physical exam takes practice. Ask your patient to push and pull their arms toward and away from you when their elbows are bent. standards. Note the size in mm before shining light. Pupillary Response Size. and how long in seconds each eye takes to constrict. shape. Altman. Each pupil should have consensual light reflex. Ask your patient to perform straight leg raises with and without resistance (tests for strength and symmetry of strength in lower extremities). while providing some resistance. 2010). and protocols. Ask your patient to dorsiflex and plantarflex their feet. 2010). The Glasgow Coma Scale The Glasgow Coma Scale assesses how the brain functions as whole and not as individual parts (Altman. Rechecking Sensory Function Test your patient’s ability to feel light touch on each extremity. Each pupil should constrict briskly when a light is shined into the eyes. 2008. Scores of less than 7 reflect coma. Provide some resistance. and symmetry of both pupils should be the same. test both sides at same time for bilateral comparison (tests for strength and symmetry of strength in upper extremities). compare bilaterally as well as upper and lower extremities. evidence presented. reassessments must occur on a periodic basis. and facility policies. Using the scale consistently in the setting allows healthcare providers to share a common language and monitor for trends across time (Jarvis. motor response. It is not enough to simply ask the right questions and perform the physical exam. A completely normal person will score 15 on the scale overall. test both sides at same time for bilateral comparison (tests for strength and symmetry of strength in lower extremities). and verbal response.Rechecking Motor Function Assess your patient’s position (looking for any abnormal positioning or posturing). Material Protected by Copyright . you must critically analyze all of the data you are obtaining. Note the size in mm after constriction. Knowing when and how often to reassess is based on the specific patient. and identify a plan of care for your patient based upon this synthesis. As the patient’s nurse. synthesize the data into relevant problem areas. test both sides at same time for bilateral comparison (tests for strength and symmetry of strength in the upper extremities). Test your patient’s ability to distinguish between a sharp or dull object on each extremity. Ask your patient to squeeze your fingers with their hands and let go. compare bilaterally as well as upper and lower extremities. The scale assesses three major brain functions: eye opening. How often these reassessments occur is unique to each patient and is based upon their physical disorder.

Snyder.: Pearson Education. PA: Lippincott. affiliates. Rapid Assessment: A flowchart guide to evaluating signs and symptoms.. Kozier.). Material Protected by Copyright . S. Louis: W. G.IMPORTANT INFORMATION: This publication is intended solely for the educational use of healthcare professionals taking this course from RN. (2006). & Black. B. F.). Saunders.). Healthcare providers.) (2009). NY: Springer Publishing. (ed. AMN Healthcare. Inc.com in accordance with RN. hospitals and healthcare organizations that use this publication agree to hold harmless and fully indemnify RN. References Altman. Philadelphia: F. & Hartlage. Fundamental and advanced nursing skills. Essentials of neuropsychological assessment: Treatment planning for rehabilitation. and employees. Springhouse. R. Strub. Davis Co.aans. Philadelphia: F.)..A. Upper Saddle River. St. (2000). L. N. (2008). (8th ed. C. Organizations using this publication as a part of their own educational program should review the contents of this publication to ensure accuracy and consistency with their own standards and protocols. Inc. process. and is not designed to address any specific situation. © Copyright 2004. Kozier & Erb's Fundamentals of nursing: Concepts. (Ed. Williams & Wilkins.com terms of use. and practice. Jarvis.W. S. 2011 from http://www.. subsidiaries. & Erb. from any and all liability allegedly arising from or relating in any way to the use of the information or products discussed in this publication.org/Patient%20Information/Conditions%20and%20Treatments/Anatomy%20of%20th e%20Brain.B. Tabers® cyclopedic medical dictionary. Physical examination and health assessment.). Venes. in assessing and responding to specific patient care situations. Retrieved April 10. including its parents. The guidance provided in this publication is general in nature. American Association of Neurological Surgeons. D’Amato. (2008).. D.com and may not be reproduced or distributed without written permission from RN. Folin.J. directors. healthcare professionals must use their judgment.B. (4th ed. (21st ed.. Clifton Park. Anatomy of the brain. The contents of this publication are the copyrighted property of RN. (2008).. The mental status examination in neurology. R. G.A. A.com. NY: Delmar.aspx Berman. (2010). as well as follow the policies of their organization and any applicable law. (3rd ed. As always. (2004). Davis Co. (5th ed). officers.com.

Sign up to vote on this title
UsefulNot useful