Ch.30 Neurological Assessment

  1. when to assess
    • •Neurological examination
    • is not applied in its entirety to asymptomatic, otherwise healthy people.

    • •It is, however, a good
    • idea to practice the exam even when working with normal patients.
  2. part of neurological assessment
    •Mental Status

    •Cranial Nerve Assessment

    •Muscle Strength and Tone

    •Reflexes – Not generally done by nurses
  3. Mental status
    •General appearance and behavior

    •Mood and Affect

    •Level of consciousness

    •Intellectual function


    • •Recent
    • and remote

    • –Emotional
    • status

    • –Thought
    • Content

    • •A client’s cultural and educational background should be taken
    • into consideration when evaluating mental status
  4. Glasgow Coma Scale
    •Best eye opening response

    •Best verbal response

    •Best motor response


    •Maximum score 15

    •Minimum score 3

    • •A score of less than 8 is considered to
    • indicate unconsciousness
  5. Glasgow coma scale
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  6. Variation in examinations
    • •Be aware of normal
    • physiologic changes

    • •Be aware of stiffness of
    • muscles and joints from aging changes or history of orthopedic surgery

    • •Expose only areas to be
    • examined

    • •Permit ample time to
    • answer questions and assume desired positions

    • •Be aware of cultural
    • differences

    • •Arrange for an
    • interpreter if needed

    • •Ask clients how wish to
    • be addressed

    • •Adapt techniques to any
    • sensory impairment
Card Set
Ch.30 Neurological Assessment