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Nursing RETDEM-Checklist of Neurological System
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Nursing RETDEM-Checklist of Neurological System as a summary study lecture class material for a better understanding of diverse clinical nursing skills.
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Nursing Care Management 101HEALTH ASSESSMENT
Procedural Checklist in Assessment Of Neurological System
Name: _____ Date: ______Year/Sec: ___ Rating:
General Objectives: To administer neurological exam and assess cranial nerve status
with maximum comfort and safety for the patient and nurse.
Specific Objectives:
1. To know the basic anatomy and function of cranial nerves
2. Obtain an accurate nursing history of a client neurological status.
3. Perform assessment of the cranial nerves using the correct techniques.
4. To be able to understand and carry out a bedside assessment of cranial nerve
function.
5. Differentiate between normal and abnormal findings of the nervous system.
6. Analyze the data gathered to formulate valid nursing diagnosis.
CRITERIA:
Item Descriptors Verbal Interpretation
Weight
1 Excellent Performed the procedure with great ease and confidence,
observing work ethics (prudent, accepts criticisms and
suggestions), able to rationalize scientifically and shows
diligence in documenting observations at all times .
0.75 Very Performed the procedure with less confidence, observing
Satisfactory work ethics (prudent, accepts criticisms and suggestions),
able to rationalize scientifically and shows minimal
diligence in documenting observations.
0.5 Satisfactory Performed the procedure but requires close supervision
and shows potential for improvement.
0.25 Needs Failed to perform the procedure, unable to function well
Improvement and needs repeated specific/ detailed guidance or
direction.
, I. Skills 1 0.75 0.5 0.25 Remarks
1. BASIC NURSING SKILLS
Prepare necessary equipment
Introduce self.
Check patients identity
Explain procedures
Secure informed consent.
Maintain privacy
Position the patient appropriately
Wear adequate PPE
Perform hand hygiene.
2. CN I- Olfactory
Using familiar scent test one nostril at
a time by occluding the other nostril
3. CNII- Optic
Inspection of pupil size, shape,
equality or any defects or foreign
bodies
Assess pupillary reflexes by asking
patient to look at distant object using
penlight shine from the side bringing
into the eye
Test for accommodation by using a
pen asking patient to focus and bring
10cm apart from the face
Test for visual acuity by asking
patient to read Snelen Chart.Cover
one eye and allow to read, do the
same on the other eye
Test visual field by tesing peripheral
vision. Cover one eye, ask client to
focus on your nose and by using
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