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PROCEDURE CHECKLIST
Neurologic Health Assessment
ILO: The student will practice beginning nursing skills in promoting healthy physiologic responses
to health / illness.
Key:
3 : Correctly and confidently performed the skill
2 : Able to perform skill; requires moderate reinforcement
1 : Skill not preformed correctly; needs re-demonstration
3 2 1
1. Prior to performing the procedure, introduce self and verify
the client’s identity using agency protocol. Explain to the
client what you are going to do, why it is necessary, and how
he or she can participate. Discuss how the results will be
used in planning further care or treatments.
2. Perform hand hygiene and observe other appropriate
infection prevention procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
presence of pain in the head, back, or extremities, as well as
onset and aggravating and alleviating factors; disorientation
to time, place, or person; speech disorder; loss of
consciousness, fainting, convulsions, trauma, tingling or
numbness, tremors or tics, limping, paralysis, uncontrolled
muscle movements, loss of memory, mood swings; or
problems with smell, vision, taste, touch, or hearing.
EVALUATION OF MENTAL STATUS
LANGUAGE
5. If the client displays difficulty speaking:
• Point to common objects, and ask the client to name them.
• Ask the client to read some words and to match the printed
and written words with pictures.
• Ask the client to respond to simple verbal and written
commands (e.g., “point to your toes” or “raise your left arm”).
ORIENTATION
6. Determine the client’s orientation to time, place, and
person by tactful questioning. Ask the client the time of day,
date, day of the week, duration of illness, city and state of
residence, and names of family members. Ask the client why
he or she is seeing a health care provider.“Why” questions
may elicit a more accurate clinical picture of the client’s
orientation status than questions directed to time, place, and
person. To evaluate the response, you must know the correct
answer. If the client cannot answer these questions
accurately, also include assessment of the self by asking the
client to state his or her full name.
MEMORY
7. Listen for lapses in memory. Ask the client about difficulty
with memory. If problems are apparent, three categories of
memory are tested: immediate recall, recent memory, and
remote memory.
To Assess Immediate Recall
• Ask the client to repeat a series of three digits, spoken
slowly.
• Gradually increase the number of digits until the client fails
to repeat the series correctly.
• Start again with a series of three digits, but this time ask the
client to repeat them backward. The average person can
repeat a series of five to eight digits in sequence and four to
six digits in reverse order.
St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines
22. CN VIII–Uses:
a. Watch-tick test for hearing.
b. Weber and Rinne test for air and bone conduction.
c. Romberg test for balance (if not already done).
23. CN IX and X–observe ability to talk, swallow, and cough.
24. CN IX and X, motor function–ask client to say “ah” while
depressing tongue with a tongue blade and observing the
soft palate and uvula to rise.
25. CN IX and X, sensory function–touch the back of pharynx
with tongue blade to induce a gag reflex.
26. CN IX and X, taste (sweet, salty, sour)–tests on posterior
portion of tongue.
27. CN XI (if not assessed with musculoskeletal exam):
a. Place hands on client’s shoulders and has client shrug
his shoulders against resistance.
b. Have client turn his head from side to side against
resistance.
28. CN XII–have the client:
a. Say “d, l, n, t.”
b. Protrude the tongue and move it from side to side.
29. Test each of the following deep tendon reflexes: biceps,
triceps, brachioradialis, patellar, and Achilles.
30. Test plantar superficial reflex (Babinski Reflex) with
thumbnail or pointed object. Strokes sole of foot in an arc
from the lateral heel to medially across the ball of the foot.
31. REFLEXES
Test reflexes using a percussion hammer, comparing one
side of the body with the other to evaluate the symmetry of
response.
0 No reflex response
+1 Minimal activity (hypoactive)
+2 Normal response
+3 More active than normal
+4 Maximal activity (hyperactive)
32. BICEPS REFLEX
Support the patient's forearm by resting it on the forearm of
the examiner, with the arm midway between flexion and
extension. Tap briskly. The forearm should flex at the elbow.
33. TRICEPS REFLEX
With the elbow in flexion, tap the triceps tendon, just proximal
to the elbow, with a reflex hammer. The arm could also be
abducted at the shoulder for this maneuver. There should be
a reflex contraction of the triceps muscle (elbow extension).
34. BRACHIORADIALIS REFLEX
Tap the brachioradialis muscle tendon at its point of insertion
onto the styloid process of the radius. A normal reflex would
produce flexion and supination of the forearm.
35. PATELLAR REFLEX
Slightly lift up the leg under the knee and tap the patellar
tendon with a reflex hammer. There should be a reflex
contraction of the quadriceps muscle (knee extension). If
performed in a sitting position, have the legs dangle over the
edge of the chair or table.
36. ACHILLES REFLEX
Slightly externally rotate at the hip, and gently dorsiflex the
foot, tapping the Achilles tendon with a reflex hammer. There
should be a reflex contraction of the gastrocnemius muscle
(plantar flexion).
GROSS MOTOR AND BALANCE TESTS
37. WALKING GAIT
Ask the client to walk across the room and back, and assess
the client’s gait.
38. ROMBERG TEST
Ask the client to stand with feet together and arms resting at
the sides, first with eyes open, then closed. Stand close
St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines
manner.
• Allow at least 2 seconds between each test to prevent
summation effects of stimuli (i.e., several successive stimuli
perceived as one stimulus).
52. POSITION OR KINESTHETIC SENSATION
Commonly, the middle fingers and the large toes are tested
for the kinesthetic sensation (sense of position).
• To test the fingers, support the client’s arm and hand with
one hand. To test the toes, place the client’s heels on the
examining table.
• Ask the client to close the eyes.
• Grasp a middle finger or a big toe firmly between your
thumb and index finger, and exert the same pressure on both
sides of the finger or toe while moving it.
• Move the finger or toe until it is up, down, or straight out,
and ask the client to identify the position.
• Use a series of brisk, gentle up-and-down movements
before bringing the finger or toe suddenly to rest in one of the
three positions.
53. Document findings in the client record using printed or
electronic forms or checklists supplemented by narrative
notes when appropriate. Describe any abnormal findings in
objective terms, for example, “When asked to count
backwards by threes, client made seven errors and
completed the task in 4 minutes.” Report deviations from
expected or normal findings to the primary care provider.
SOURCE:
Berman, A. &. (2012). Kozier & Erb's Fundamentals of Nursing, 9th Ed. New Jersey: Pearson.
Fullname ad
Grade/ signature of
Qualitative description of student’s performance
Remarks clinical
instructor/Date
Very satisfactory performance. Student showed
basic competency in performing the procedure,
Competen showed mastery in understanding the rationale
90-99
t behind all the actions, and was able to execute all
the steps on his/her first attempt of return
demonstration.
Satisfactory performance. Student showed basic
competency in performing the procedure, showed
Partially
mastery in understanding the rationale behind all
Competen 80-89
the actions, and was able to execute 80% of all
t
the steps on his/her first attempt of return
demonstration.
St. Paul University Surigao
St. Paul University System
8400 Surigao City, Philippines
Remarks: