Ch.30 Neurological Assessment

• •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.

•Mental Status

•Cranial Nerve Assessment

•Muscle Strength and Tone

•Reflexes – Not generally done by nurses

•General appearance and behavior

•Mood and Affect

•Level of consciousness

•Intellectual function

–Memory

• •Recent
• and remote

• –Emotional
• status

• –Thought
• Content

• •A client’s cultural and educational background should be taken
• into consideration when evaluating mental status

•Best eye opening response

•Best verbal response

•Best motor response

Score

•Maximum score 15

•Minimum score 3

• •A score of less than 8 is considered to
• indicate unconsciousness

• •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