Checklists for Clinical Nursing Skills

29

Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-8 Undertaking a neurological examination

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed accurately without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.  1. Identify the patient.  2. Check the medical order or clinical pathway/care plan.  3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent.  4. Gather the necessary equipment. Equipment: pen torch, different scents, tendon hammer, tongue depressor, cotton wool, blunt needle, two objects familiar to the patient, reading material, tuning fork.  5. Undertake a risk assessment, if indicated.  6. Perform hand hygiene.  7. Put on personal protective equipment (PPE), if indicated.  8. Ensure patient privacy is maintained and that interruptions are minimal.  9. Undertake a health history, as per Skill 2-1. 10. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a supine position. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Survey the patient’s overall hygiene and physical appearance. 12. Assess the patient’s mental status. 13. Evaluate level of consciousness (Glasgow Coma Scale— GCS). (a) Assess eye opening. (b) Evaluate the patient’s best verbal response: orientation to person, place and time. (c) Assess the patient’s best motor response. (d) Assess pupil response and size. (e) Document the GCS score. (f) Assess memory (immediate recall and past memory). (g) Assess abstract reasoning by asking the patient to explain a proverb, such as ‘The early bird catches the worm’.

Comments

Excellent

Satisfactory

Needs practice

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Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.