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.
3.
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
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.
6.
Documentation and analysis of assessment data with nursing diagnoses
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.
II.
MENTAL STATUS
A.
General appearance and behavior
B.
Level of consciousness
C.
Intellectual performance
D.
Emotional status
CRANIAL NERVES
A.
Olfactory (I)
B.
Optic (II)
C.
1.
visual acuity
2.
visual fields
3.
fundoscopic
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.
2.
Sensory
a.
light touch
b.
pain
c.
corneal reflex
Motor
a. masseter and temporal muscles
E.
Facial (VII)
1.
sensory - anterior tongue
2.
motor - facial movements
F.
G.
H.
Acoustic (VIII)
1.
watch tick
2.
Weber
3.
Rinne
Glossopharyngeal (IX) and Vagus (X)
1.
swallowing
2.
rise of soft palate
3.
gag
Spinal Accessory (XI)
1.
strength of tongue
2. strength of sternocleidomastoid & neck
I.
III.
Hypoglossal (XII)
1.
protrude tongue
2.
strength of tongue
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.
IV.
heel-shin
REFLEX STATUS 0-4+ Very brisk/hyperactive (Upper motor neuron disease possible)
A.
B.
C.
Biceps C5-6
Brachiordialis C5-6
Triceps C6,7
D.
E.
Patellar L2,3,4
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