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GEORGIA BAPTIST COLLEGE OF NURSING

OF

MERCER UNIVERSITY

HEALTH ASSESSMENT (NURN211)

ASSESSMENT OF THE NEUROLOGICAL & MUSCULOSKELETAL SYSTEMS

Lesson Outcomes:

1. Demonstrate appropriate techniques for neurologic assessment by: inspection, cranial nerve and sensory testing, proprioception and cerebellar function testing, reflex testing, and by techniques to elicit sensations of pain, touch, vibration, position sense, and fine touch. C1:P2:L3-2b; C2:P2:L3-2d

2. Demonstrate techniques to assess motor movement and strength. C1:P2:L3-2b; C2:P2:L3-2d

3. Differentiate between normal and abnormal findings with age differences of the adult client. C3:P6:L3-6d

4. Recognize expected and unexpected outcomes of mental status by appearance, orientation, thought content and processes, mood and affect, judgment, and abstract reasoning C3:P6:L3-6d

5. Considering review of systems and client history, document a neurologic and musculoskeletal

assessment accurately and comprehensively. C1:P2:L3-2b

6. Analyze neuro-muscular findings to identify actual and potential health problems and risks. C4:P6:L3-6d

Content Outline:

1. Mental Status Assessment

1.1. appearance

1.2. behavior

1.3. communication

1.4. abstract thinking & judgment

2. Assessment of the neurologic system

2.1. health history data

2.2. cerebral function

2.3. cranial nerve assessment

2.4. sensory responses

2.5. reflexes

2.6. cerebellar function

3. Assessment of the motor system

3.1 range of motion and muscle strength

3.2 limb measurements

3.3 spinal, hip, and knee assessment

4. Abnormal findings & related pathology:

4.1. Compartment syndromes - Phalens test

4.2. Herniated Nucleous Pulposes (HNP)

4.3. Brudzinski’s sign for meningitis

4.4 Knee ballottement, Lachman test, and McMurrays

5. Documentation and analysis of assessment data with nursing diagnoses

6. Symptom analysis and documentation

Teaching/Learning Activities:

1. Case study/discussion

2. View videotapes: NeuroScience Nursing: "Increased Intracranial Pressure"

3. Laboratory demonstration/practice of assessment techniques Nursing Series: Neurological Deficits

4. Review CD prior to class

5. Documentation

Required Readings:

Chapter 6: Mental Status Assessment

Chapter 22: Musculoskeletal System

Chapter 23: Neurological System

Rev.5/08 HH

EXAMPLES OF RECORDING FOR THE PHYSICAL EXAM

NEURO/MUSCULOSKELETAL

Face:

Symmetrical at rest and with movement, jaw muscles strong, no crepitation or limitation in movement of temporomandibular joint.

Sensory: pain and light touch intact.

Eyes:

Vision (distant with glasses): R, 20/40; L, 20/30; can read newspaper at 18 in. Visual fields full.

Extraocular movements: bilaterally intact; no nystagmus, ptosis, lid lag.

Pupils: PEERLA

Fundoscopic examination: normal veins and arteries; disc

round, margins well defined, color yellowish pink; macular areas normal; no arteriovenous nicking, hemorrhages, or exudates.

Corneal reflex: present bilaterally.

Ears:

Hearing: finger rub heard in both ears at 3 ft.

Weber test: no lateralization.

Rinne test: AC 2x > BC bilaterally.

Nose:

Able to identify odors bilaterally.

Oral cavity:

Palate: intact, moves symmetrically with phonation, gag reflex present.

Tongue: strong, midline, moves symmetrically.

Taste: able to differentiate sweet and sour.

Neck:

Full ROM, strong symmetrically.

Neural system:

Alert, oriented x3; mood appropriate and stable; remote and

recent memory intact; several calculations by 6 accurate; insight normal; cranial nerves intact, examined and recorded in head and neck regions; all movement coordinated; able to perform rapid coordinated movements with upper and lower extremities.

Reflexes: 2+ through out. (see chart)

Sensory: light touch, pain, and vibration to face trunk, and extremities intact and symmetrical; position sense intact bilaterally in upper and lower extremities; walks with coordination, able to maintain standing position with eyes closed (Romberg intact).

Extremities and musculoskeletal system:

Muscular development and mass normal for age; arms and legs symmetrical; skin warm, soft, neither moist nor dry; normal male hair growth on arms; legs, and feet; no edema; varicosities, or tenderness; joints nontender, not swollen; normal ROM; muscle tone and strength normal bilaterally;

ROM; no tenderness or deformities.

neuro.211 DD/1991;5/95/hh; 10/97/hh/lmw; Rev hh 3-04

NEUROLOGICAL EXAM

I. MENTAL STATUS

A. General appearance and behavior

B. Level of consciousness

C. Intellectual performance

D. Emotional status

II. CRANIAL NERVES

A. Olfactory (I)

B. Optic (II)

1. visual acuity

2. visual fields

3. fundoscopic

C. Oculomotor (III), Trochlear (IV) &

Abducens (IV)

1. cardinal fields of gaze

2. oculomotor's other functions

a. direct, consensual constriction

b. accommodation

D. Trigeminal (V)

1. Sensory

a. light touch

b. pain

c. corneal reflex

2. Motor

a. masseter and temporal muscles

E. Facial (VII)

1. sensory - anterior tongue

2. motor - facial movements

F. Acoustic (VIII)

1. watch tick

2. Weber

3. Rinne

G. Glossopharyngeal (IX) and Vagus (X)

1. swallowing

2. rise of soft palate

3. gag

H. Spinal Accessory (XI)

1. strength of tongue

2. strength of sternocleidomastoid & neck

I. Hypoglossal (XII)

1. protrude tongue

2. strength of tongue

III. CEREBELLAR FUNCTION (BALANCE & COORDINATION)

A. Whole body coordination

1. gait

2. heel-toe

3. Rhomberg; pronator drift

4. Deep knee bend

B. 1. Upper body

2. finger-nose

3. point-to-point

C. Lower body

1. heel-shin

IV. REFLEX STATUS 0-4+ Very brisk/hyperactive (Upper motor neuron disease possible)

A. Biceps C5-6

B. Brachiordialis C5-6

C. Triceps C6,7

D. Patellar L2,3,4

E. Achilles S1

V. MOTOR SYSTEM

A. Muscle size

B. Muscle tone

C. Muscle strength

D. Involuntary movements

1. Tremors:

Intention,

Resting,

Postural

VI. SENSORY SYSTEM

A. Light touch

B. Pain

C. Vibration (tuning fork extremities/joints)

D. Motion and Position

E. Two-point discrimination (normal 2-3mm)

F. Point localization

G. Stereognostic function

H. Graphesthesia

Neuro 211

Rev 3/04 hh

GEORGIA BAPTIST COLLEGE OF NURSING

OF

MERCER UNIVERSITY

Mental Status Assessment

Appearance--grooming, posture, facial expression, gait mannerisms

Behavior--eye contact, speech patterns, tone of voice, clarity of speech, body language

Consciousness--sensorium, (altered, confused, unresponsive), attentiveness to environment

Mood and Affect

Cognitive functioning

Orientation

Time

Place

Person

Attention and Concentration

Digit Span

Serial sevens or threes

Simple arithmetic calculations

Memory

Recent--What did client have for breakfast? Give address to remember and ask about it five minutes later.

Remote--Ask client his/her birthday. List grades in school.

Fund of Knowledge (General intelligence, nonstandardized)

Aware of current events

Can name last 3-5 presidents

Can name governor of state and mayor of city

Knows nation's capitol

Can name the seasons of the year

Abstract Thinking

Proverbs

Judgment

Insight--Client's thoughts about present situation.

Perception and Coordination

Write name or sentence

Draw common figures

Thought Processes-ability to form associations and connections

between thoughts

Blocking

Circumstantiality

Tangentiality

Confabulation

Looseness of associations

Flight of ideas

Perseveration

Word salad

Thought Content

Obsessive

Somatic

Violent

Presence of hallucinations, illusions and/or delusions

Judgment

Letter found on street

Smoke in crowed movie theater

Documentation of Mental Status Assessment

The client is a 25 year old, well-groomed woman who speaks clearly and coherently to the examiner. Oriented x 3. Able to remember 7 digits forward and 5 backward. No difficulty with serial sevens or arithmetic calculations. Recent and remote memory intact. Fund of knowledge and intelligence adequate. Able to abstract proverbs--when asked "Don't cry over spilled milk, " responded, "Don't focus on a situation that can't be corrected. No problems with perception and coordination as evidenced by figure drawings. Though content appropriate--no evidence of suicidal/homicidal thoughts, denies delusions, hallucinations and illusions. Judgment intact--would mail stamped, addressed letter found on the street.

N. Ice: Winter/1991

Reviewed 10/92/NI, 11/93

Revised 6/93/NI; 5/95/hh

mntl-lab.211

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