Assessment Tool for Nervous System

7/30/2019 Assessment Tool for Nervous System

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ASSESSMENT TOOL FOR NERVOUS SYSTEM

BIOGRAPHICAL DATA

NAME- HOSPITAL-

AGE- WARD-

SEX- UNIT-

NATIONALITY- I.P. NO-

RELIGION- BED NO-

EDUCATION- DOCTOR-

OCCUPATION- DIAGNOSIS-

ADDRESS- DATE OF ADMISSION-

CHIEF COMPLAINTS-

1.

2.

3.

4.

HISTORY OF PRESENT ILLNESS-

Head Ache

OnsetSudden( ) / Gradual ( )

Site- Frontal ( )/ Occipital ( )/ Temporal( )

Location- Unilateral ( )/ Bilateral ( )


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Quality- Dull ( )/ Aching ( )/ Steady ( )/ Boring ( )/ Burn ( )/ Intermittent(

)/ Continuous( )/ Paroxysmal ( )

DurationDays ( ) / Weeks ( ) / Months( ) / Years( )

Precipitating factors- Environmental ( )/ Foods( )/ Exertion ( ) / Coughing ( )/Straining ( )

Relieving factors- Analgesics ( )/ Food( ) /Heat ( )/ Rest ( )/ Neck Massage( )

Associated factors- Nausea ( )/ Vomiting ( )/ Weakness ( ) /Numbness In The

Extremities ( )

Seizure

Onset- Gradual( ) / Sudden( )

QualityAcute( ) / Intermittent( )/ Continuous ( )

Type- Tonic Seizures ( ) / Clonic Seizures( ) / Tonic-Clonic Seizure/ ( )Atonic Seizures(

)/ Myoclonic Seizures( )

Precipitating Factors- High Fever( ) / Alcohol( )/ Drug Withdrawl( ) / Hypoglycemia (

)/ Brain Lesions( )

Relieving Factors- Rest And Sleep( ) / Medications( )

Visual Disturbance

Onset Sudden ( )/ Gradual ( )

Site One Eye ( ) / Both Eyes ( )

Duration Days ( )/ Weeks ( ) / Months ( ) Years ( )

Diplopia Present ( )/ Absent ( )

Nystagmus Present ( )/ Absent ( )

Hemianopsia- Present ( )/ Absent ( )

State of Consciousness

TypeUnconscious ( ) / Semi-Conscious ( ) Conscious( ) Drowsy ( )


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OrientationPlace ( )/ Time ( )/ Person( )

Duration - Intermittent( )/ Continuous ( )/ Days( )/Weeks( )

Memory- Present ( ) / Absent( )

JudgementPresent ( )/ Absent ( )

Speech disturbances

Onset- Sudden ( )/ Gradual ( )

Quality- Acute( ) / Intermittent ( )/ Continuous( ) / Chronic( )

Difficulty In Articulation (Aphasia)- Yes ( ) / No( )

Difficulty In Expression (Expressive Aphasia)- Yes( ) /No( )

Difficulty In Understanding (Receptive Aphasia)- Yes( ) /No ( )

Motor disturbances

OnsetSudden( )/ Gradual ( )

FrequencyIntermittent( ) / Continuous( ) / Acute ( ) / Chronic ( )

Duration- Days ( )/ Weeks ( ) / Months( )

Precipitating Factors- Walking( ) / Activities( )

Relieving Factors- Rest ( ) / Position( )

Hemiplegia- Yes ( ) / No ( ) , If Yes Specify

AtaxiaYes ( ) / No( ) . If Yes Specify

Dysarthria- Yes ( ) / ( ) No , If Yes Specify

Dysphagia- Yes ( ) / No( ), If Yes Specify

Sensory Disturbances

OnsetSudden( )/ Gradual ( )

Quality- Acute( ) / Intermittent( ) /Continuous( ) / Chronic ( )


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Duration- Days ( ) / Weeks( ) / Months ( )

PainYes ( ) / No ( )

Numbness/ Tingling- Yes ( ) / No( ), If Any Specify

Relieving Factors- Rest ( )

Precipating Factors- Walking ( ) / Neck Movement ( )

Cognitive Disturbance

Onset- Gradual ( )/ Sudden ( )

Memory Loss- ShortTerm ( ) / Long-Term ( )

Attention Span- Good ( ) / Deficit( )

Abstract Reasoning-Present( ) / Absent( )

JudgmentGood( ) / Poor( )

Emotional Disturbance

Emotional Lability- Good( ) / Poor( )

Self-Control- Present( ) / Absent ( )

Feelings Of Isolation- Present ( ) / Absent ( )

WithdrawalPresent( ) / Absent( )

PAST MEDICAL HISTORY

Previous health status- good /average/ poor

Previous hospital admission

Date Age at

admission

Reason for

admission

Treatment of

hospital

Outcome Follow-up


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History of surgery- yes / no, if yes specify

History of STDyes/ no , if yes specify

History of any childhood disease- yes / no , if yes specify

History of adulthood disease- yes / no , if yes specify

History of traumatic injury- yes/no , if yes specify

History of allergies- yes/ no

Food / drugs/ cosmetics/ environmental factors/ medication

PRESENT SURGICAL HISTORY-

Any surgery to be done, if yes

Name of the surgery Body part Type of anaesthesia


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PAST SURGICAL HISTORY

History Of Previous Surgery- Yes ( ) / No ( )

Name Of The Surgery- Hospital Name- Duration Of Hospital Stay-

Any Complication-

PERSONAL HISTORY

Smoking- Yes( ) / No( ) , If Yes, No . Of ( ) Per Day

Drinking- Yes( ) / No( ) . Habitual( ) / Social( ) / Specify( )

Sleep And Rest- Total No. Of Sleep-

Rest-

Bowel And Bladder- Bowel Regular( ) / Irregular ( ) /Constipation( ) /

Diarrhea( )

Bladder- Frequency Of Micturition( ) / Retention( ) /

Incontinence ( ) / UTI( )

Dietary Pattern- Vegetarian ( ) / Non- Vegetarian ( )

Likes-

Dislikes-

Allergic To Food Stuffs-

Any Specific Food Fads-

ExercisesActive ( ) / Passive ( ) / Range Of Motion ( )

FAMILY HISTORY

Type Of Family-

Number Of Family Members-

Marital HistoryMarried( ) / Unmarried( ) / Widow( ) / Single( )


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Consanguineous Marriage- Yes ( ) / No( )

Hereditary disease-

Pedigree tree-

ENVIRONMENTAL HISTORY

Name Of The Place-

Ventilation

Type Of The House- kaccha( ) / Pucca( )

Drainage-Open( ) / Closed( )

Water Supply- Well ( ) /Public Tap( ) / Bore Well( )

Toilet Facilities

SOCIO-ECONOMIC HISTORY

Education-

No. Of Earning Members-

Total Family Income-

Family Class- Low( ) / High( ) / Middle( )

Type Of Work- Heavy ( ) / Moderate /( ) / Sedentary( )

PYSCHO SOCIAL HISTORY

Interpersonal relationship with family members, neighbors, friends and attitude towards each other-

PHYSICAL EXAMINATION

General Appearance- Moderate Built ( )/ Thin( ) / Obese ( )

Nourishment- Well Nourished( )/ Under Nourished( )/ Malnourshment( )

HealthHealthy( )/ Unhealthy( )/ Repeated Infections( ).

Height-


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Weight-

State Of Comfort- Comfortable( ) /Distressed( )

Mental status examination

A. Glasgow Coma ScalePatients response to stimuli 6 5 4 3 2 1

Eye opening

SpontaneouslyTo voice

To pain

None

Best verbal response

Oriented

Confused

Inappropriate wordsIncomprehensible sounds

None

Best motor response

Obeys command

Localizes painWithdraws

Flexion

ExtensionNone

Total

Conscious ( ), Semi-Conscious ( ) , Unconscious ( )

Mood and affect - Pleasant ( )/Depressed ( ) /Cooperative( ) / Inco Operative(

) / Agitation( ),/Anger( ) / Euphoria( )

Thought Content- Illusions( )/, Hallucinations( )/, Delusion ( )


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Intelligence Capacity- Retardation( ), Dementia( ), Intelligence( )

Orientation- to place/ to time/ to person

Memory- RecentGood( ) / Deficit( )

Remote- Good( ) / Deficit( )

Immediate- Good( ) /Deficit( )

Verbal memory- Good( ) /Deficit( )

Visual memory- Good( ) /Deficit( )

Judgement And Insight

Reasoning Ability- Appropriate( ) / Inappropriate ( )

Abstract Thinking- Appropriate( ) / Inappropriate ( )

Problem Solving- Accurate( ) / Inaccurate ( )

Language And CommunicationClear( ) /Slurred( ) / Dysphonia( ) / Dyarthria( ) /

Aphasia-Auditory( )/Visual ( )/Expressive Speaking ( )

Expressive Writing ( )

PerceptionAgnosiaVisual( ) / Auditory( )/ Tactile( )/ Body Parts( )

Speech - VolumeLoud ( ) / Normal( )/Soft( )Tonality- Monotonous, ( ) Tremulous( )

Quantity - Minimal( )/Voluble( )

Ease Of Conversation

Cranial Nerve Assessment

I Olfactory Nerve- Sense Of Smell, Normal( )/ Ansomia( )

II Optic Nerve- Visual Acuity- Normal. ( ) Myopia( ) / Hypermetropia( )

Visual Field-Normal( ) / Unilateral Loss( ) / Bilateral Loss( ) /

Peripheral Loss( )

Fundus Laceration-Blood Clot( ) / Papilledema ( ), Diabetic

Retinopathy(


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Accommodation- Present( ) / Absent( )

Ptosis- Present( ) / Absent( )

IV Trochlear- Extra Ocular Movement-Intact ( )/ Nystagmus ( ) /Diplopia ( )

V TrigeminalMastication- Normal( )/ Abnormal( )

Jaw MovementNormal( )/ Difficult( )/ Absent( )

MouthAble To Open Widely( ) / Able To Open With Resistence( ) /

Unable( )

Pain Sensation- Absent ( )/ Present( )

Touch- Temperature-Cold( )/Warm( )

Corneal Reflex- Present( )/ Absent( )

VI Abducens-Ocular Movement- Vertical( ) / Horizonta( )l/ Rotational( )

VII Facial Nerve- Symmetry( )/ Asymmetry ( ) , Smile-Present( )/Absent( )

Whistle- Present( ) /Absent ( ) Close The Eye Tightly- Present( ) /Absent(

Purse The Lip- Present ( ) /Absent( ) Raised Eyebrow- Able To Do( )/

Unable( )

Taste- Present( )/ Absent ( )

VIII Vestibulocochlear (Acoustic Nerve)Hearing Acuity- Present( ) / Absent( )

Bone Conduction Hearing LossPresent( )/ Absent( )

Air Conduction Hearing Loss- Present( )/ Absent( )

IX Gloss Pharyngeal Nerve-

Position Of Uvula And Palate- Normal ( )/ Abnormal( ) / Swallowing Ability( )

TasteNormal ( )/ Abnormal( )

Voice- Normal( )/ Hoarseness( )/ Nasal Voice( )

X Vagus Nerve

Gag Reflex- Present( ) /Absent( )

Cough Reflex- Present( ) / Absent( )

XI Spinal Accessory Nerve

Movements Of Sternocleidomastoid And Trapezious Muscle- Present( ) / Absent( )


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Elevation Of ShoulderPresent( ) /Absent ( )

Chin Movement- Present ( )/Absent( ) Head Movement- Present( )/Absent( )

XII Hypoglossal nerve-

Tongue movementstick out( ) / side to side ( ) / up( ) /down( )

MOTOR SYSTEM

Muscle Size- Symmetry ( )/ Asymmetry ( ) /Hypertrophy( ) / Atrophy( )

Muscle Strength- 5/5( ) , 4/5( ).3/5( ), 2/5( ), 1/5( ),0/5( )

Weakness( ), Pronator Drift( )

Muscle Tone- Hypotonia( ) , Hypertonia ( ) , Myoclonus ( ) , Athetosis ( ) ,

Chorea( ) Dystonia ( )

GaitNormal ( ) / Shuffling( ) / Weak( ) / Unsteady( ) / Ataxia( )

Movement- Fasciculation- Present( ) /Absent( )

Pain- Present( ) /Absent( )

Joint Contracture- Present ( ) /Absent( )

Muscle Resistance- Present ( ) /Absent( )

SENSORY FUNCTION

Sensory

Function

Touch Pain Temperature Vibration Position

Face

Arms

Legs

HandsFeet


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BALANCE AND CO ORDINATION

Posture- good/ deficit

Finger to nose test- good/ poor

Pronation and supinadtion hand- good/ average/ poor

Dysartheria- present/absent

Heel- toshin test- good/average/poor

REFLEXES

Superficial reflexes Positive Negative

Corneal

Gag or swallowing

Abdominal

Cremasteric(men only)

Plantar

Perianal

Deep reflexes No reflex 0 Hypoactive

+1

Normal +2 Increased +3 Hyperactivity

+4

Biceps

Triceps

Brachioradialis

Patellar

Ankle


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VITAL SIGNS

Temperature:

Pulse;

Respiration:

Blood pressure:

INVESTIGATIONS-

Date Investigation Patients Values Normal Values Inference

SPECIAL INVESTIGATIONS-

TREATMENT

Sn

o

Date DrugName

Dose Frequency Time Action Side Effects NursesResponsibility


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NURSING DIAGNOSIS

1.

2.

3.

4.

5.


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Assessment Tool for Nervous System