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It is the process of evaluating the level of consciousness using a tool (GCS/NVS scale). It
is a key component in the acre of neurologic patient which help detect the presence of
neurological disease or injury.
Purposes:
1. To assess patient’s level of consciousness.
2. To establish baseline data to compare subsequent assessment findings.
3. To detect the presence of neurological disease or disorder.
4. To determine the type of care to provided.
Materials Needed:
1. Percussion hammer
2. Wisps of cotton to asses light touch sensation
3. Sterile safety pin for tactile discrimination
Assessment
1. Review physician’s order for neurovital Ensure correct monitoring of patient.
signs/GCS monitoring.
2. Assess reason for NVS/GCS monitoring. Determines the need for monitoring.
Planning
5. Gather all the materials/equipment To prevent delay of the procedure and to
needed. save time and effort.
6. Plan the need for assistance. Another person’s support during the
procedure may facilitate ease of
procedure.
HEEL-TOE WALKING
Ask the client to walk a straight line,
placing the heel of one foot directly in
front of the toes of the other foot.
12. Fine Motor Tests for the Upper This will evaluate if the hands develop
Extremities dexterity and strength.
FINGER-TO-NOSE TEST
Ask the client to abduct and extend the
arms at shoulder height and then rapidly
touch the nose alternately with one index
finger and then the other. The client
repeats the test with the eyes closed if the
test is performed easily.
FINGER-TO-NOSE AND TO
THE NURSE’S FINGER
Ask the client to touch the nose and then
your index finger, held at a distance of
about 45 cm (18 in.), at a rapid and
increasing rate.
FINGERS-TO-FINGERS
Ask the client to spread the arms broadly
at
shoulder height and then bring the fingers
together at the midline, first with the eyes
open and then closed, first slowly and then
rapidly.
13. Fine Motor Tests for the Lower The ability to perform these tasks requires
Extremities properly functioning pyramidal
Ask the client to lie supine and to perform (corticospinal) and extrapyramidal tracts,
these tests. sensation and coordination.
Implementation
7. Introduces self and verify the client’s
identity. Explains to the client about the
procedure and discusses how the results
will be used in planning further care or
treatments.
8. Provides client privacy.
KNOWLEDGE (15%)
1. Gives rationale of the procedure
2. Explain the elements and mechanics of
the procedure
3. Knows the elements of nursing process
as applied
4. States principles applied in procedure
ATTITUDE (10%)
1. Is well groomed
2. Wears the prescribed, neat and clean
uniform
3. Arrives on time for the RD
4. Speaks to CI and client tactfully
5. Minimizes use of energy, time and effort
6. Utilizes supplies efficiently
7. Considers client safety, privacy and
comfort
8. Is well organized
9. Keeps working area clean at all times
10. Gives high value for aesthetics
Comments:
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