Plantar flexion strength is assessed while the nurse applies some resistance to the bottom of the feet while asking the patient to push (i.e., step on the gas).
General leg strength can be assessed by asking the patient to dorsiflex, plantar flex, and bend each knee.ĭorsiflexion strength can be assessed by asking the patient to pull up on their feet while the nurse applies some resistance to the top of the feet. General arm and hand strength can be assessed by asking the patient to extend their arms and grip the nurse’s hands simultaneously. Figure 2.7 Assessing hand strength Assess dorsiflexion Assess plantar flexion Communication barriers related to language differences between the patient and healthcare givers might be alleviated through interpreters making information available in the patient’s language.Ĭommunication barriers related to neurological impairment require further investigation and a creative approach during patient care. Neck pain and stiffness (nuchal rigidity) may be related to old injury or signs and symptoms of a serious neurological illness.ĭifficulty communicating may be the result of a language barrier or neurological impairment. Impaired neck ROM may indicate an old injury. This includes flexion, extension (front and back, and side to side) and ability to rotate the neck side to side. Unusual finding should be followed-up with a swallow assessment and a referral to an occupational therapist. Frequent coughing or choking associated with eating or drinking may suggest risk of aspiration. Dental disease can influence one’s general health.ĭifficulty swallowing may suggest neurological impairment. Inspect mouth, tongue, and teeth for moisture, colour, dentures, hygiene.ĭry mucous membranes may indicated altered hydration. Unusual findings should be followed-up with a focused respiratory assessment. Nasal flaring or use of accessory muscles when breathing may indicate altered breathing patterns. Unusual findings should be followed up with a focused neurological system assessment.Įvidence of nasal trauma. Figure 2.6 Observe for facial asymmetryįacial asymmetry may indicate neurological impairment or injury. People who need these devices but don’t have them, or if the devices are not in working order, may experience some level of isolation because of difficulty interacting with the world around them.
The extent of eye contact may reflect cultural norms, individual way of being, or possibly mental health issues. Note nature of eye contact during interview. The nurse would further their questioning to elicit greater understanding, and potentially to refer to other healthcare professionals subsequently.Īltered LOC may indicate substance use, fatigue, brain injury, neurological disorder, mania, or depression.ĭrainage from eyes or nose may indicate infection, allergy, or injury. If appearance is unkempt, it may suggest that the patient struggles with achieving activities of daily living. Observations about general appearance may provide insight into other physical or psychosocial issues affecting the patient. General appearance Figure 2.5 Observe general appearance Objective Data Consider the following observations. Document according to agency guidelines.Use appropriate listening and questioning skills.Be organized and systematic in your assessment.Confirm patient ID using two patient identifiers (e.g., name and date of birth).The last part of the checklist provides some guidelines for some elements of a focused neurological assessment.Ĭhecklist 16 provides a guide for subjective and objective data collection in a neurological assessment.Ĭhecklist 16: Head and Neck / Neurological Assessment Figure 2.4 Nervous system Disclaimer: Al ways review and follow your agency policy regarding this specific skill. In some situations a more focused neurological assessment is necessary. The first part of the checklist provides a general overview of performing a basic neurological assessment.
It exerts unconscious control over basic body functions, and it also enables complex interactions with others and the environment (Stephen, Skillen, Day, & Jensen, 2012). A neurological assessment begins when the nurse first interacts with the client and involves observations about appearance, communication patterns, and general behaviour. The neurological system is responsible for all human function. 2.6 Head-to-Toe Assessment: head and neck / Neurological Assessment
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