HEALTH ASSESSMENT PRACTICUM
Methodological Instructions to Lesson ¹ 30 for
Students 1 course BACHELOR DEGREE NURSING PROGRAM
(practical lesson-7 hours)
Themes: Health
assessment of Neurological system..
Aim: The
purpose of this program is to provide nurses an understanding of the health
assessment of the neurologic system, including
cranial nerves, sensory responses, reflex responses,
sense of position, two-position discrimination, balance, muscle tone, symmetry,
and strength.
Professional orientation of students:
Assessment of the neurological systems, including mental status, is a
component of a complete physical assessment. In addition, the promotion of
neurological/mental health is a critical aspect of preventative nursing care.
This class will provide the student with an understanding of neurological
system/mental status assessment and the importance of maintaining their
integrity.
Themes: Health
assessment of Neurological system..
Control questions:
1.
Recall anatomy and
physiology of the neurological system.
2.
Describe questions and related rationale used
to obtain health history data about the neurological system.
3.
Develop a systematic
approach to symptom analysis for the commonly occurring problems of headache,
dizziness or vertigo, seizures, changes in consciousness, altered mobility,
altered sensation, dysphasia, and aphasia.
4.
Describe preparatory
guidelines including equipment needed for the assessment of the neurological
system.
5.
Describe assessment techniques
for the following: speech; cranial nerves; cerebella function for balance and
coordination; extremities for muscle strength; sensation, and deep tendon
reflexes; and super reflexes.
6.
Describe normal assessment
findings relative to the neurological system.
7.
Discuss age-related and
cultural considerations relative to the assessment of the neurological system.
8.
Discuss health promotion
practices relative to assessment of the neurological system.
9.
Identify common variations
(health alterations) of neurological system.
TEST
QUESTIONS:
1. Which of the following
substances or conditions depresses nerve cell activity?
|
a. |
Caffeine |
|
b. |
Acidosis |
|
c. |
Alkalosis |
|
d. |
Theophylline |
____ 2. Which of the
following deficits should the nurse expect to find in a client who has
experienced an injury to the frontal lobe of the brain?
|
a. |
Inability to interpret taste sensations |
|
b. |
Inability to interpret sound |
|
c. |
Impaired judgment |
|
d. |
Impaired learning |
____ 3. A client is
receiving a drug that stimulates the sympathetic division of the autonomic
nervous system. What effects on the heart should the nurse expect from the
administration of this medication?
|
a. |
Decreased heart rate, decreased force of contraction |
|
b. |
Increased heart rate, increased force of contraction |
|
c. |
Decreased heart rate, increased force of contraction |
|
d. |
Increased heart rate, decreased force of contraction |
Answers:
1. ANS: B
Acidosis depresses the threshold of the nerve membrane
so that less stimulus is needed to generate and transmit an impulse.
PTS: 1 DIF: Cognitive Level: Knowledge TOP: Nursing
Process Step: N/A
MSC: Client Needs Category: Physiological Integrity
2. ANS: C
The frontal lobe is responsible for many functions;
among them are judgment, reasoning, voluntary eye movement, and motor
functions.
PTS: 1 DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Assessment MSC: Client
Needs Category: Physiological Integrity
3. ANS: B
Stimulation of the sympathetic nervous system
initiates the fight-or-flight response, increasing both the heart rate and
force of contraction.
PTS: 1 DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis MSC: Client
Needs Category: Physiological Integrity
4. ANS: A
4.
LITERATURE
A
lecturer notes (handouts).
Essential
books:
1.
Miller Alistair W.F. et al (1998): Obstetric illustrated, 5th ed,
2.
Hacker & Moore, (1998): Essential of Obstetric and Gynecology, 3rd
ed, W.B. Saunders Company,
3.
Fraser Dian M, et al, (2003): Myles textbook for midwives, 14th ed, Elsevier science limited, china.
4.
Ladwing Patrica W, et al,
(2003): Maternal and newborn nursing. 1st ed,
Addison wesley longman,
5.
neuroexam.com
http://www.neuroexam.com/
5. Practical
work – 900-1200 (4 hours)
Visual Aids and Material Tools: Tables, slides, compact-disk
Task 1.
Identify health history questions for assessment of
the neurological system.
A neurological health history can be obtained if the patient is alert
enough and oriented to person, place, and time. If the person appears to be
disoriented or confused upon questioning, ask family members and friends to
confirm the information. The person should be questioned as to previous history
of seizures, loss of consciousness, anesthesia (an absence of normal sensation
– especially to pain), paresthesia (numbness and
tingling; a “pins and needles” feeling), neuralgia, twitches, tremors,
personality changes, memory deficits, mental deterioration, nervousness,
anxiety, history of psychiatric problems, vertigo, sensory disturbance,
phobias, hallucinations, delusions, illusions, nightmares, insomnia, and/or
grandiose ideas.
Task 2. Assess Level of Consciousness
a. Arousal (Wakefulness)
i.
Voice
Stimulation
ii.
Shouting
iii.
Shaking
iv.
Painful
Stimuli (Central/Peripheral)
b. Awareness
i.
Orientation
ii.
Language
iii.
Memory
Task 3. Assess Cranial Nerve Function
c. Olfactory (I)
i.
smell
d. Optic (II)
i.
Visual
acuity (Snellen Chart)
ii.
Visual Fields by
Confrontation (Peripheral Vision)
iii.
Ophthalmoscope
exam (Optic disk)
e. Oculomotor (III), Trochlear
(IV), Abducens (VI)
i.
Pupil
Size, Shape and Equality
ii.
Pupil Reaction to Light
(Direct and Consensual)
iii.
Accommodation
Reflex
iv.
Extraocular movements in 6 Cardinal Fields of Gaze
v.
Doll's Head Maneuver
(Doll's eyes)
f. Trigeminal (V)
i.
Clench teeth (temporal and Masseter Muscles)
ii.
Corneal
Reflex
iii.
Sharp
vs. Dull
iv.
Light
touch (Cotton ball)
g. Facial (VII)
i.
Symmetry
of face
ii.
Facial Movements (raise
eyebrows, frown, smile, puff cheeks, close eyes)
iii.
Taste of sweet, sour, and
salt (bitter-CN IX)
h. Acoustic (VIII)
i.
Hearing
ii.
Weber
and Renne Test
i.
Glossopharyngeal (IX) and Vagus (X)
i.
Uvula
midline
ii.
Gag
Reflex
iii.
Swallowing
iv.
Bitter taste-usually tested
with CN VII
j.
Spinal
Accessory (XI)
i.
Shrug
shoulders
ii.
Rotate
head
k. Hypoglossal (XII)
i.
Tongue
movement
Task 4. Assess
Motor Response
Motor performance is
dependent on:
a. Muscle tone
i.
Hypotonia
(LMN)
ii.
Hypertonia
(UMN)
b. Posturing
i.
Decortication-interruption of the corticospinal tracts
(Flexion)
ii.
Decebration -midbrain and upper pons (Extension)
c. Involuntary Movements
i.
Intention
tremors
ii.
Nonintention
tremors
iii.
Postural
tremors
iv.
Tics
v.
Choriform
Movements
vi.
Athetosis
vii.
Dystonia
viii.
Fasciculations
ix.
Myoclonus
x.
Tardive
Dyskinesia
d. Muscle Strength
i.
Grade
0-No Muscle Contraction (0%)
ii.
Grade
1-Trace (10%)
iii.
Grade 2-Active movement in
the absence of gravity (25%)
iv.
Grade 3-Active movement
against gravity (50%)
v.
Grade 4-Active Movement
against some resistance (75%)
vi.
Grade 5-Full Motor Strength
against resistance (100%)
e. Hand Grasps
f. Foot Pushes
g. Pronator Drift
h. Muscle size
i.
Atrophy
(LMN)
ii.
Hypertrophy
(UMN)
Task 5. Assess
Coordination
a. Assess Gait
i.
Hemiplegic
ii.
Spastic
iii.
Involuntary
Movements of Gait
iv.
Ataxic
(cerebellar)
v.
Steppage
(foot drop)
vi.
Festination
Gait (Parkinson's Gait)
vii.
Scissors
Gait
viii.
Waddling
Gait
b.
Heel-to-toe (Tandem walk)
c. Walk on Heels
d. Walk on Toes
e. Romberg test
f.
Hop in Place on one foot
g. Shallow knee bends
h. Rapid Rhythmic Alternating
Movements
i.
Pat
leg
ii.
Turn
hand over and back
iii.
Touch
each finger with thumb
iv.
Pat examiner's hand with
ball of foot
i. Point to Point Testing
i.
Touch index finger and nose
rapidly
ii.
Run heel of foot down
opposite shin
iii.
Figure
8 with foot
Task 6. Assess Sensory System
j.
Pain/Temperature
i.
Analgesia
ii.
Hyperalgesia
k.
Light touch
i.
Anesthesia
ii.
Hyperesthesia
l.
Vibration
m. Position Sense
n. Discriminative Sensations
i.
Sterognosis
ii.
Graphesthesia
(number identification)
iii.
Point
Localization
iv.
Two
Point Discrimination
Task 7. Assess Reflexes
Evaluates 1) sensory nerve;
spinal cord; motor nerve; muscle group
Grading Reflexes
DEEP TENDON
REFLEXES
a.
Biceps
Reflex-Cervical 5,6
b.
Triceps
Reflex- Cervical 7,8
c.
Brachioradialis
Reflex - Cervical 5,6
d.
Patellar
Reflex (knee reflex) - Lumbar 2,3,4
e.
Achilles
Reflex - Lumbar 5, Sacral 1,2
SUPERFICIAL
REFLEXES
a. Plantar Response (Babinski)
- Lumbar 4,5, Sacral 1,2
b. Abdominal Reflexes -
Thoracic 8,9,10,11,12
c. Cremasteric Reflex
FRONTAL RELEASE
SIGNS
a.
Grasp
Reflex (Palmar Grasp)
b.
Snout
Reflex
c.
Glabella
(Myerson's Sign)
d.
Sucking
and Rooting
e.
Plantar
Grasp
f.
Moro
g.
Tonic
Neck
h.
Step
in place
MENINGEAL
SIGNS
a. Brudzinski's Sign- Flexion
of Neck
b.
Kernig's Sign - Flexion of Hip and Knee
6. Seminar
Discussion of practical work – 12.30-14.45 (2 hours)
7. Test control of students’ knowledge – 1415-1500
(1 hour).
Basic
level:
Student
must know:
1. Structure
and function of central nervous system and peripheral nervous system
2. Structure
and function of cranial nerves
3. Subjective
data
4. Developmental
considerations
5. Abnormal
findings
6.
Differentiate between
normal and abnormal assessment findings of the neurological system.
7.
Identify health promotion
needs of clients based on findings of the neurological assessment.
Student
must have the skills:
1. Inspection
and palpation of the motor system
2. Assessment
of the sensory system
3. Testing
cranial nerves
4. Testing
reflexes
5. Demonstrate health assessment of the neurological system.
6. Accurately
record the assessment
Prepared by Dr.
Inna Korda, MD, PhD.
Adopted at the Chair Sitting N 2008