Head to Toe Assessment – Neurological – Flashcards

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Do you have any severe headaches?

Do you have any dizziness?

Have you had any past head injuries?

Do you have any difficulty swallowing?

• Ask client: What is your name? • Where are you at the moment? • What time did you arrive here? "Client awake, alert, and oriented X3 to person, place, and time"

• Look at face to see if it relaxed "Facial expression is appropriate to situation and changes appropriately to the situation, person is clean and well groomed, hair is neat and clean, posture is erect and relaxed, affect is appropriate to situation"

• Recent—24-hour diet recall/ what time did you arrive here • Remote—Who was President before Obama? What were you doing on 9/11/2001? "Person is able to recall what time they arrived at facility and what they were doing on 9/11/2001"

• What is 100 - 5? (95, 90, 85, 80, 75, 70, 65, 60, 55, 50...) "Person is able to do simple math problem"

• Give a series of directions and note correct sequence of behavior • "Please take this with your right hand, put it in your mouth, take it out with your left hand, and place in trash can" "Person able to concentrate when given instructions"

• Never judge a book by its cover—What does that mean? (Never judge person w/o getting to know them) "Person able to interpret proverb"

• Occlude one nostril and ask client to sniff, repeat w/ opposite nostril • Ask patient to close eyes, occlude one nostril; present aromatic substance to each nostril "Nostrils patent bilaterally, no obstructions; patient able to identify two aromas"

"Patient able to read specified line OD 14/14, OS 14/14; visual fields intact by confrontation"

• Inspect for drooping of upper lid (ptosis) or sagging of the eyes • Ask person to look at your nose while covering one eye w/ card. Observe the uncovered eye (should be steady), remove the card from covered eye and it should stare straight ahead at your nose • PERRLA—Check for pupils size, shape, regularity, equality, and direct (cover one eye and shine pen light, note constriction of pupil), and consensual (have a barrier between eyes and shine light from the side and make sure pupils constrict at the same time) light reaction and accommodation (focus on far object then near) "EOMs intact, no muscle weakness, pupils are equal and round, react to light and accommodate, no presence of drooping, ptosis, or nystagmus"

• Ask person to clench teeth—should feel equally strong • Try to separate jaws by pushing down on chin • Ask patient to close eyes; touch patient w/ cotton ball and ask patient to say now when felt (forehead, cheeks, chin) • Tell client to identify the sensation felt, sharp or dull, with eyes closed "Jaw strength equal bilaterally; temporalis and masseter muscles equally strong bilaterally, sharp vs. dull sensation intact and equal bilaterally; light touch sensation intact and equal bilaterally"

"Facial movements symmetric bilaterallyace""

"No tenderness or pain noted upon palpation"

"Uvula is midline and rises w/ phonation; gag reflex present and patient able to swallow and cough"

"Shoulder shrugs and head movement equally strong bilaterally"

"Tongue is midline, no tremors, present; lingual speech is distinct and clear"

• Ask client to close eyes • Apply a twisted cotton wisp over skin @ random sites and irregular intervals • Client say "now" when touch felt "Light touch felt over hands, arms, legs, feet bilaterally"

• Ask client to close eyes • Apply vibrating tuning fork on bony prominence • Client indicate when vibration starts and stops "Vibrations felt on bony prominences of fingers and big toe"

• Ask client to close eyes • Hold client's digits by the side • Move client either up or down, varying movements "Movements detected accurately"

• Client close eyes • Place familiar object in clients hand • Client identify object "Client able to identify objects bilaterally"

"Client able to identify number bilaterally"

• Stabilize persons arm w/ 1 hand • Have client flex elbow against your resistance applied just proximal to wrist • Ask client to extend elbow against your resistance "Muscle strength of biceps and triceps equally strong bilaterally"

Point-to-Point •Client use index finger to touch examiners finger •Client place index finger to their nose •Perform few times moving your finger to different spots Finger-to-Nose •Ask client to close eyes •Client stretch out his/her arms •Client touch tip of his/her nose w/ alternating index finger and increasing speed Heel-to-Shin •Place client in supine position •Ask client to place heel of 1 foot on opposite knee •Client run heel down shin to the ankle Tandem Walking •Ask client to walk straight line in heel-to-toe fashion "Finger to nose and point to point movement smooth and accurate; heel to shin patient able to move heel in a straight line; tandem walking is straight and balanced"

•Biceps—hold elbow, ask patient to relax arm, strike thumb •Triceps—hold forearm from back, ask patient to relax, "let arm go dead", strike right above the elbow •Patellar—let lower legs dangle freely, strike directly below the patella "DTRs of biceps, triceps, and patellar are 2+ bilaterally"

•Stroke up the lateral edge and across the ball of client's feet (upside down J) "Babinski's reflex is negative"

"Romberg test negative"

•Ask client to walk 10-20 ft, turn around and return to starting point "Gait is smooth, rhythmic, and effortless; arm swing freely, turn is smooth"