Health History

 Before you begin the health history, keep in mind that the
patient may be experiencing confusion, impaired verbal
communication, memory loss, personality changes, or other
deficits.This may affect her or his ability to provide reliable
information, so verifying subjective data with a family member or
friend may be wise.
Rather than asking a long series of questions, it may be best to
encourage the patient to tell her or his story without
interruption.You can learn a great deal from the content of the
story and also by listening to the way it is told. If time is an
issue and you are unable to perform a complete health history,
perform a focused history on the sensory-neurologic system.

Focused Sensory-Neurologic History

 Your patient’s condition or time restraints may prohibit taking a
detailed neurologic history. If so, ask questions that focus on a
history of neurologic problems, the presence of neurologic
symptoms, identification of risk factors, and health promotion
activities. The patient’s response to these questions will help
direct your assessment. Key questions include:
o Do you have any neurologic problems?
o Do you have any other medical problems?
o Are you taking any medications?
o Do you have a history of head trauma, LOC, dizziness,
headaches, or seizures?
o Do you have memory problems or changes in your senses?
o Do you have weakness, numbness, or paralysis?
o Do you have problems walking or performing activities of
daily living (ADLs)?
o Do you have mood problems or depression?
o Do you use drugs or alcohol?
o Do you have allergies?
o Have you ever been treated for a neurologic or psychiatric
problem?
o When did your symptoms start?

Biographical Data

 As always,review the patient’s biographical data for clues that

relate to the neurologic system. Obviously, the patient’s age and
educational level will influence the questions you ask and the
type and extent of teaching you provide. Keep in mind that
certain neurologic disorders are age related.For example,the
incidence of stroke increases with age,and neurologic diseases
such as myasthenia gravis (MG) and multiple sclerosis (MS)
usually attack young women with a peak age between 20 and 30
years. Spinal cord injuries occur more frequently in young people
because of the higher rate of accidents. Also, some neurologic
disorders are gender related. For example, women have a higher
 incidence of hemorrhagic stroke, whereas men have more thrombic
strokes; before age 40, MG occurs in women two to three times
more often than in men;and the incidence of MS is higher in women
than in men.Even geographical locale influences some types of
neurologic diseases.
Ask adolescents and adults about their job history. Could they
have been exposed to neurotoxins? Have they had a head or back
injury? Marital status, such as a recent divorce or death of a
spouse, can certainly influence neurologic findings.A patient’s
spiritual beliefs may also influence how he or she perceives
illness (e.g., as a punishment) and how he or she deals with
illness (e.g., the Christian Science belief in healing through
mental and spiritual means).
Symptoms
Headache
 Headache is the most common neurologic symptom.The causes are
many.The pain may be mild or severe,acute or chronic, localized
or generalized. Ninety percent of all headaches are benign in
nature, caused by muscle contraction (tension) and/or vascular
(migraine and cluster); the other 10 percent have underlying
pathology.Because a headache may be a symptom of a serious
medical problem, a careful, thorough symptom analysis is needed
to determine the cause.

Mental Status Changes

 Mental status changes are an early indication of a change in
neurologic status.The changes may be very subtle and difficult to
detect.They may begin slowly as forgetfulness, memory loss, or
inability to concentrate, or rapidly proceed to unconsciousness.
Causes include neurologic problems, fluid and electrolyte
imbalance, hypoxia, low perfusion states, nutritional
deficiencies, infections, renal and liver disease, hyper- or
hypothermia,trauma,medications,and drug and alcohol abuse.If your
patient’s mental status is severely impaired, ask family members
to describe the changes that have occurred.

Dizziness, Vertigo, and Syncope

 Dizziness, vertigo, and syncope are common neurologic signs and
symptoms that warrant further investigation. Dizziness is a
“fainting” sensation, whereas vertigo is a sensation that the
surroundings are spinning around (objective vertigo) or that the
person is spinning around (subjective vertigo).Vertigo is often
accompanied by nausea and vomiting, nystagmus, and tinnitus.
Dizziness can lead to syncope,which is a temporary loss of
consciousness.The patient may say that he or she “blacked out” or
“had a spell.” Although the underlying cause of these signs and
symptoms may be benign, they may also indicate a serious
problem,such as an impending stroke,and need to be investigated
thoroughly.
Numbness or Loss of Sensation Numbness or tingling
 Is referred to as paresthesia. Possible causes include diabetes
and neurologic, metabolic, cardiovascular, renal, and inflammatory
diseases. Determine the area affected and the onset and
progression of symptoms.

Deficits in the Five Senses

 Assess changes in any of the five senses. Intact cranial nerves
are essential for many of the senses.CN I (olfactory) is
responsible for the sense of smell; CN II (optic), III
(oculomotor), IV (trochlear), and VI (abducens) are responsible
for visual acuity, pupillary constriction, and extraocular
movement (EOM); CN VII (facial) and IX (glossopharyngeal) control
taste; CN VIII (acoustic) controls hearing; and CN V (trigeminal)
and dermatomes control somatic sensations.
Visual problems are a frequent symptom associated with neurologic
disorders and should be further assessed. Visual changes can
result from ocular, neurologic, or systemic problems, eye or head
trauma, or adverse effects from drugs.The anatomic position of
the cranial nerves that control the eye makes the nerves
vulnerable to increases in intracranial pressure (ICP). These
visual changes can be total loss of vision,visual field
cuts,blurred vision,diplopia (double vision),photosensitivity,and
amaurosis fugax (unilateral vision loss, as if a shade were being
pulled down, resulting from insufficient blood supply to the
retina and lasting up to 10 minutes).The visual deficit may have
an acute or gradual onset and be permanent or temporary.
Past Health History
 The purpose of the past medical history is to compare it with the
patient’s present neurologic status or uncover risk factors that
might predispose the patient to neurologic disorders.The
following questions will guide you in exploring specific areas
related to the sensory-neurologic system.
SBAR
S- Situation: What is going on with the patient? What is the situation
you are calling about?
This includes patient identification information, code status, vitals,
and the nurse’s concerns.
 Identify self, unit, patient, room number.
 Briefly state the problem, what is it, when it happened or
started, and how severe.
B-Background: What is the key clinical background or context?
Pertinent background information related to the situation could
include the following:
 The admitting diagnosis and date of admission
 List of current medications, allergies, IV fluids, and labs
 Most recent vital signs
 Lab results: provide the date and time test was done and results
of pervious tests for comparison
 Other clinical information
 Code status
A- Assessment: What do I think the problem is? What is the nurse’s
assessment of the situation?
Here the nurse indicates what he or she believes to be the problem
based on client history and current assessment.
R-Recommendation: What do I recommend or what do I want you to do?
What is the nurse’s recommendation or what does he/she want?
Physician follow-up actions are suggested, including possible tests.
Examples:
 Notification that patient has been admitted
 Patient needs to be seen now
 Order change