critical Demonstrated? element? Yes No 1. Introduced self and verified client’s identity. 2. Explained procedure to client and discussed how results will be used. 3. Gathered appropriate equipment. 4. Performed hand hygiene and observed other appropriate infection prevention procedures. 5. Provided for client privacy. 6. Inquired about the client’s history related to the neurologic system. 7. If the client displayed difficulty speaking, pointed to common objects and asked client to name them. Asked the client to read some words and to match the printed and written words with pictures. Asked the client to respond to simple verbal and written commands. 8. Determined the client’s orientation to time, place, and person. 9. Listened for lapses in memory. Asked the client about difficulty with memory. Tested immediate recall, recent memory, and remote memory if lapses were apparent. 10. Tested the ability to concentrate or maintain attention span. Tested the ability to calculate. 11. Applied the Glasgow Coma Scale. 12. Tested each cranial nerve not already evaluated in another component of the health assessment. 13. Tested for Babinski reflex 14. Tested gross motor function and balance. 15. Performed fine motor tests for upper extremities. 16. Performed fine motor tests for lower extremities. 17. Tested light-touch sensation. 18. Assessed pain sensation. 19. Tested position or kinesthetic sensation.
Used effective body mechanics throughout procedure.
Communicated appropriately with the client. Documented all relevant information.
Name: Gerald Age: 3 Years Old Current Diagnosis: Imperforate Anus Nursing Care Plan Cues/Clues Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation