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NUR 101 Neurological Assessment ATI Template
- Cours
- NURSING 101
- Établissement
- Bay State College
Comprehensive and detailed ATI template on; Neurological Assessment for Nur 101. *Essential Study Material!!
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ACTIVE LEARNING TEMPLATE: Nursing SkillJessica Willard
STUDENT NAME _____________________________________
Neurological assessment
SKILL NAME ____________________________________________________________________________ REVIEW MODULE CHAPTER ___________
Description of Skill
Neurological assessment is an evaluation of a person's nervous system, which includes the
brain, spinal cord, and the nerves that connect these areas to other parts of the body.
Indications CONSIDERATIONS
The nervous system consists of the brain, the spinal cord,
and the nerves from these areas. There are many aspects Nursing Interventions (pre, intra, post)
of this exam, including an assessment of motor and 1.Mental status. Mental status (the patient's level of awareness and interaction with the environment) may be assessed by conversing
with the patient and establishing his or her awareness of person, place, and time. The person will also be observed for clear speech
sensory skills, balance and coordination, mental status (the and making sense while talking. This is usually done by the patient's healthcare provider just by observing the patient during normal
interactions.
patient's level of awareness and interaction with the 2. Motor function and balance. This may be tested by having the patient push and pull against the healthcare provider's hands with his
or her arms and legs. Balance may be checked by assessing how the person stands and walks or having the patient stand with his or
her eyes closed while being gently pushed to one side or the other. The patient's joints may also be checked simply by passive
environment), reflexes, and functioning of the nerves. (performed by the healthcare provider) and active (performed by the patient) movement.
3. Sensory exam. The patient's healthcare provider may also do a sensory test that checks his or her ability to feel. This may be done
-The extent of the exam depends on many factors, by using different instruments: dull needles, tuning forks, alcohol swabs, or other objects. The healthcare provider may touch the
patient's legs, arms, or other parts of the body and have him or her identify the sensation (for example, hot or cold, sharp or dull).
including the initial problem that the patient is experiencing, 4. Reflexes in the older child and adult. These are usually examined with the use of a reflex hammer. The reflex hammer is used at
different points on the body to test numerous reflexes, which are noted by the movement that the hammer causes.
the age of the patient, and the condition of the patient. 5. Coordination exam: Using rapid alternating movement, Point-to-point movement, Romberg's test, and Proprioception.
6. Pupil Scale (2-9 mm)
7. Cranial Nerves Assessment:
Cranial nerve I (olfactory nerve). This is the nerve of smell. The patient may be asked to identify different smells with his or her eyes
closed.
*Cranial nerve II (optic nerve). This nerve carries vision to the brain. A visual test may be given and the patient's eye may be examined
with a special light.
Cranial nerve III (oculomotor). This nerve is responsible for pupil size and certain movements of the eye. The patient's healthcare
provider may examine the pupil (the black part of the eye) with a light and have the patient follow the light in various directions
Outcomes/Evaluation
Client Education
Identify patient Neurological Status.
Teach patient to attempt tasks that they are
comfortable to prevent falls
Potential Complications Nursing Interventions
Risk for falls. Do not force patient to attempt tasks that
-Increase patient distress. beyond their limitations and be prepare to
catch patient when assessing Gait, Balance,
and Coordination.
ACTIVE LEARNING TEMPLATES
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