Matt Josh Eurick L.

Aseo
Name of the Student ______________________________ A-17
Section______ 11/05/2022
Date__________________ Score _______
Diane Vince Igot Lim
Name of Clinical Instructor _____________________________________

ASSESSING THE NUEROLOGIC, MUSCULOSKELETAL AND PERIPHERAL VASCULAR SYSTEM

BEFORE PROCEDURE
1. Identify the patient
2. Explain the purpose of the head and neck examination
and answer any question.
3. Instruct the patient to void if possible. Collect a urine
specimen if ordered.
4. Perform a hand hygiene
5. Help the patient undress if needed and provide a
patient gown.
6. Begin with a survey of the patient’s overall hygiene and
physical appearance.
ASSESSING NEUROVASCULAR SYSTEM NORMAL FINDINGS DEVIATION FROM NORMAL
1. Assess the patients’ mental status A. The patient is oriented.
a. Evaluate the patient’s orientation to person, place and B. The patient is conscious.
time. C. The patient was able to immediately recall and past memory
b. Evaluate level of consciousness. D. The patient was able to explain.
c. Assess memory (immediate recall and past memory) E. The patient fully understand spoken and written words.
d. Assess abstract reasoning by asking the patient to explain
a proverb, such as “The Early Bird Catches The Worm”
e. Evaluate the patient’s ability to understand spoken and
written word.
2. Test for Cranial Nerve Functions. E A. The patient was able to identify the smell of different substances.
a. Ask the patient to close the eyes, occlude one nostrils and B. The patient has 20/20 vision. Pupils are round and reactive to
then identify the smell of different substances such as light and accommodation.
coffee, chocolate or alcohol. Repeat with the other C. The patient’s eyes move in the direction as they follow the
nostrils. penlight.
b. Test for visual acuity and pupillary constriction.
c. Move the patient’s eyes through the cardinal position of
D. No signs of difficulty as the patient smiles, frowns, wrinkles her
gaze. forehead and puff out her cheeks.
d. Ask the patient to smile, frown, wrinkle forehead and puff E. The patient was able to repeat the whispered words without
out cheeks. difficulty.
e. Test hearing F. The patient’s gag reflex is present.
f. Test the gag reflex by touching the posterior pharynx with G. Patient was able to shrug her shoulder against resistance. She
the tongue depressor. Explain to patient that this may be was also able to turn her head from left to right.
uncomfortable.
g. Place your hands on the patient’s shoulder’s shoulders
while he or she shrugs against the resistance. Then place
your hand on the patient’s left cheek, then the right cheek,
and have the patient push against it.
3. Inspect the ability of the patient to move his neck. Ask Patient was able to move her neck without difficulty or showing any
the patient to touch his/her chin to chest and to each signs of pain.
shoulder each ear to the corresponding shoulder and
then tip head back as far as possible.
4. Inspect the upper extremities. Observe for skin color, Patient’s skin color is brown and no presence of lesion, rashes, and
presence of lesion, rashes and muscle mass. Palpate masses. There is also no presence of lesions, rashes and masses
for presence of lesions, rashes and presence of upon palpation
masses.
5. Ask the patient to extend arms forward and then rapidly Patient was able to rapidly turn palms up and down with
turn palms up and down. coordination.
6. Ask the patient to flex upper arm and to resist Patient was able to resist the force exerted by the examiner.
examiner’s opposing force.
7. Inspect and palpate the hands, fingers, wrists and No swelling of joints and bone deformities.
elbow joints palpate the hands. No masses or tenderness noted upon palpation
8. Palpate the radial and brachial pulses. Both pulses are present
9. Have the patient squeeze two of your fingers. Patient was able to squeeze the fingers tightly.
10. Ask the patient to close his/her eyes. Place a familiar The patient was able to determine the familiar objects that were
objects such as a key in the patient’s hand and ask placed on her hands.
him/her to identify the objects, Repeat on the other
hand with a different number.
11. Ask the patient to close his/her eyes. Using your finger Patient was able to identify the numbers being traced on her two
or applicator, trace a one digit number on the patient’s palms
palm and ask him or her to identify the number. Repeat
on the other hand with a different number.
12. Assist the patient to a supine position, Examine the There is no sign of discoloration on the legs and feet. No lesions,
lower extremities. Inspect the legs and feet for color, varicosities, and edema. Hair and nail growth are normal.
lesion, varicosities, hair growth, nail growth, edema and
muscle mass.
13. Test for pitting edema in the pretibial area by pressing No identation remains in the skin after the fingers have been lifted.
fingers into the skin of pretibial area. If an indentation
remains in the skin after the fingers have been lifted
pitting edema is present.
14. Palpate for pulse and skin temperature at the posterior Pulse are present at the posterior tibial, dorsalis pedis, and
tibial, dorsalis pedis and popliteal areas. popliteal areas. Skin temperature is warm to touch
15. Have the patient perform the straight leg test with one Patient was able to straighten each leg without difficulty.
leg at a time.
16. Ask the patient to move one leg laterally with the knee The patient was able to abduct the knee and adduct the hips.
straight to test abduction and medially to test adduction
of the hips.
17. Ask the patient to raise the thigh against the resistance Patient was able to endure the resistance of the opposing force. No
off your hands, next have the patient push outward signs of pain or difficulty was seen.
against the resistance of your hands, then have the
patient pull backward against the resistance of your
hand. Repeat on the opposite side.
18. Assess the patient deep tendon reflex
a. place your fingers above the patient’s wrist and tap with
 reflex hammer, repeat on the other arm.
b. Place your fingers over the antecubital area and tap with a
reflex hammer repeat on the other side.
c. Place your finger over the with a triceps tendon area and
tap with a reflex hammer, repeat on the other side.
d. Tap just below the patella with a reflex hammer, repeat on
the other side.
e. Tap over the Achilles tendon area with reflex hammer,
repeat on the other side.
19. Stroke the sole of the patient’s foot with the end of a The patient was able to respond plantar flexion of all the toes and
reflex hammer handle or other hard object such as key; inversion and flexion of the forefoot.
repeat on the other side.
20. Ask the patient to dorsiflex and then plantarflex both Patient was able to oppose the resistance without difficulty
feet against the opposing resistance.
21. As needed, assist the patient to a standing position. Patient was able to maintain her balance; has an upright posture.
Observe the patient as he/she walks with a regular gait Patient was able to maintain heel-toe walking without falling and
on the toes on the heels and then heel to toe. was unaided.
22. Perform the Romberg’s test, ask the patient to stand Patient was able to maintain an upright posture and foot stance.
straight with feet together, both eyes closed with arms
at side.. Wait for 20 second and observe for patient
swaying and ability to maintain blance. Nurse must be
alert to prevent fall or injury related to losing balance
duing this assessment.
AFTER PROCEDURE
1. Assist the patient to a comfortable position
2. Perform hand hygiene
3. Document the findings of the assessment.
RATING RATING