You will perform a history of a neurologic problem that you have experienced and perform an assessment of the neurologic system. You will document your subjective and objective findings, identify actual or potential risks
check attachments for instructions and Template.
You will perform a history of a neurologic problem that you have experienced and perform an assessment of the neurologic system. You will document your subjective and objective findings, identify actual or potential risks.
The neurologic recheck assessment is a follow up assessment performed frequently on clients who have had some kind of head injury or a systemic problem affecting the neurologic system. This type of client needs to be followed closely to identify signs of increasing neurologic deficit necessitating emergent intervention. The assessment includes:
1) the level of consciousness –are they oriented to person, place, and time?
2) motor function – can they follow commands and testing of strength?
3) pupillary response – are the pupils equal in size and shape and do they respond to light?
4) vital signs – although changes in the vital signs would occur late in the case of increased intracranial pressure.
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No need for reference or in text citation this is not a APA PAPER
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Due feb, 10th, 2022
Rasmussen University – NUR 2
1
80: Health Assessment
Instructor-Observed Skill Demonstration: Neurologic System
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Student Name: ______________________________________ Date: _________________ |
Points Possible |
Points Earned |
Comments |
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Knocks |
1 | |||||||||||||||||||
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Washes hands |
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Identifies the client with 2 identifiers |
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Provides privacy |
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Explains procedure |
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Identifies any issues that may impact client safety or personal safety |
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Mental Status |
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Assess level of consciousness and orientation to person, place, and time |
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Assess quality and appropriateness of speech |
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Cranial Nerves |
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Cranial Nerve I (Olfactory) – tests for smell |
5 |
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Cranial Nerve II (Visual) – tests for visual acuity OR peripheral vision |
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Cranial Nerves III, IV, and VI (Oculomotor, Trochlear, Abducens) – tests for 6 cardinal directions of gaze |
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Cranial Nerve V (Trigeminal) – tests for facial sensation and jaw strength |
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Cranial Nerve VII (Facial) – tests for facial movement |
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Cranial Nerve VIII ( Acoustic) – tests for hearing acuity |
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Cranial Nerve IX (Glossopharyngeal) – tests for swallow |
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Cranial Nerve X (Vagus) – tests for uvula rising with phonation |
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Cranial Nerve XI (Spinal Accessory) – tests shoulder shrug and head turn against resistance |
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Cranial Nerve XII (Hypoglossal) – tests for midline tongue protrusion |
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Reflexes |
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Triceps reflex |
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Biceps reflex |
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Brachioradialis reflex |
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Patellar reflex |
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Achilles’ tendon reflex |
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Plantar reflex |
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Coordination |
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Finger to Nose test |
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Heel to shin test |
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Romberg test |
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Motor Testing |
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Tests grip strength |
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Tests dorsiflexion and plantar flexion strength |
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Sensory Testing |
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Tests sharp and dull sensation minimum of 2 areas of arms and legs bilaterally |
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Tests position sense of 1 finger on each hand and 1 toe on each foot |
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Post-Procedure Steps |
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Inquires if the client is comfortable |
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Student is professional and courteous with their communication |
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Ensures the client has their call light |
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Ensures client’s personal items are within reach (glasses, phone, etc.) |
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Washes hands |
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Total Points Earned |
of 100 possible |
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The above named student has: |
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Passed this skill evaluation Failed this skill evaluation and must remediate. Plan for remediation: |
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Student signature and date indicating agreement with remediation plan: _____________________________________ Instructor signature and date indicating agreement with remediation plan: ___________________________________ |
Rev. 10/2018 Page 2 of 2
Title:
Documentation of problem based assessment of the neurological system.
Purpose of Assignment:
Learning the required components of documenting a problem based subjective and objective assessment of neurological system. Identify abnormal findings.
Course Competency:
Apply assessment techniques for the neurological and respiratory systems.
Instructions:
Content: Use of three sections:
· Subjective
· Objective
· Actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them.
Format:
· Standard American English (correct grammar, punctuation, etc.)
Resources:
Chapter 5: SOAP Notes: The subjective and objective portion only
Sullivan, D. D. (2012). Guide to clinical documentation. [E-Book].
Smith, L. S. (2001, September). Documentation do’s and don’ts. Nursing, 31(9), 30.
Documentation Grading Rubric- 10 possible points
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Levels of Achievement |
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Criteria |
Emerging |
Competence |
Proficiency |
Mastery |
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Subjective (4 Pts) |
Missing components such as biographic data, medications, or allergies. Symptoms analysis is incomplete. May contain objective data. |
Basic biographic data provided. Medications and allergies included. Symptoms analysis incomplete. Lacking detail. No objective data. |
Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Lacking detail. No objective data. Information is solely what “client” provided. |
Basic biographic data provided. Included list of medications and allergies. Symptoms analysis: PQRSTU completed. Detailed. No objective data. Information is solely what “client” provided. |
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Points: 1 |
Points: 2 |
Points: 3 |
Points:4 |
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Objective (4 Pts) |
Missing components of assessment for particular system. May contain subjective data. May have signs of bias or explanation of findings. May have included words such as “normal”, “appropriate”, |
Includes all components of assessment for particular system. Lacks detail. Uses words such as “normal”, “appropriate”, or “good”. Contains all objective information. May have signs of bias or explanation of findings. |
Includes all components of assessment for particular system. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident Contains all objective information |
Includes all components of assessment for particular system. Detailed information provided. Avoided use of words such as “normal”, “appropriate”, or “good”. No bias or explanation for findings evident. All objective information |
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Points: 4 |
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Actual or Potential Risk Factors (2 pts) |
Lists one to two actual or potential risk factors for the client based on the assessment findings with no description or reason for selection of them. Failure to provide any potential or actual risk factors will result in zero points for this criterion. |
Brief description of one or two actual or potential risk factors for the client based on assessment findings with description or reason for selection of them. |
Limited description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. |
Comprehensive, detailed description of two actual or potential risk factors for the client based on the assessment findings with description or reason for selection of them. |
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Points: 0.5 |
Points: 1.5 |
Clients Presentation: ( Your client can make up whatever they want. They can be as dramatic. Have fun with it!)
Subjective Data (4 points): (Review History questions. See subjective data questions in course power points to help guide you. Also, review subjective data gathering in the course text. )
Objective Data (4 points): (Use your Neurological skill demonstration sheet to help guide you.)
Mental Status Assessment-
Cranial Nerve Assessment-
Reflexes-
Coordination –
Motor Testing-
Sensory Testing-
Describe 2 Actual/Potential Risk Factors ( 2 points):
