NCM 1234: HEALTH ASSESSMENT (RLE)

NEUROLOGICAL SYSTEM

Name: _________________________________________ Section: __________ Date: ________________

Name of Patient: _________________________________ Age: ___________ Gender: ___________

HEALTH HISTORY
ASSESSMENT No Yes, Explain
1. Any unusual frequent or unusually severe
headaches?

2. Ever had any head injury?

3. Ever feel dizziness?

4. Ever had any convulsions?

5. Any tremors in hands or face?

6. Any weakness in any body part?

7. Any problem with coordination?

8. Any numbing or tingling?

9. Any problem swallowing?

10. Any problem speaking?

11. Past history of stroke, spinal cord injury,

meningitis, congenital defect, alcoholism

12. Any environmental/occupational Hazards

e.g insecticides?

PHYSICAL EXAMINATION
A. CRANIAL NERVES

I ________________________________________________________________________________________

II ________________________________________________________________________________________

III, IV, VI __________________________________________________________________________________

V ________________________________________________________________________________________

VII _______________________________________________________________________________________

IX, X ______________________________________________________________________________________

XI _______________________________________________________________________________________

XII _______________________________________________________________________________________

B. MOTOR SYSTEM
 1. Muscles:

Size, strength, tone _______________________________________________________________

Involuntary movements ___________________________________________________________

2. Cerebellar Function:

Gait ___________________________________________________________________________

Romberg Test ___________________________________________________________________

Rapid Alternate Movements _______________________________________________________

Finger-to-finger test ______________________________________________________________

Finger-to-nose test _______________________________________________________________

Heel-to-shin test _________________________________________________________________

C. SENSORY SYSTEM

1. Spinothalamic tract:

Pain ____________________________________________________________________________

Temperature ____________________________________________________________________

Light touch ______________________________________________________________________

2. Posterior Column tract:

Vibration ________________________________________________________________________

Position (Kinesthesia) ______________________________________________________________

Tactile discrimination ______________________________________________________________

Stereognosis _____________________________________________________________________

Graphesthesia ___________________________________________________________________

Two-point of discrimination ________________________________________________________

D. REFLEXES
Brachial
Biceps Triceps Patellar Achilles Abdomen Cremasteric Babinski
Radialis
R
L
0= absent, 1+=hypoactive, 2+ = normal, 3+ = hyperactive,
4+ = hyperactive with clonus, dorsiflexion, plantar flexion

Summarize your findings below:

What is your nursing diagnosis?

Source: Udan, Josie (2009). Health Assessment and Physical Examination: Concepts and Clinical Application