Preparation

Performed

Mastered

Comments

Yes No

1. Assemble equipment: Sugar, salt, lemon juice, quinine flavors Percussion hammer Tongue depressors ( one broken diagonally,

for testing pain sensation) Wisps of cotton, to assess light touch

sensation Test tubes of hot and cold water, for skin

temperature assessment (optional) Pins or needles for tactile discrimination

Procedure

1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following: Presence of pain in the head, back, or

extremities, as well as onset and aggravating and alleviating factors.

Disorientation to time, place, or person. Speech disorders. Any history of loss of consciousness, fainting,

convulsions, trauma, tingling or numbness, tremors or tics, limping, paralysis, uncontrolled muscle movements, loss of memory, or mood swings.

Problems with smell, vision, taste, touch, or hearing.

Language

5. If the client displays difficulty speaking:

Point to common objects, and ask the client to name them.Ask the client to read some words and to match the printed and written words and pictures.Ask the client to respond to simple verbal and written commands-e.g.,”Point to your toes,” or “Raise your left arm.”

Assessing the Neurological System

Orientation

6. Determine the client’s orientation to the time, place, and person by tactful questioning.

Ask the client the city and state of residence, time of day, date, day of week, duration of illness, and names of family members.

More direct questioning might be necessary for some people –e.g., “Where are you now?”, “What day is it today?”

Memory

7. Listen for lapses in memory.

Ask the client about difficulty with memory. If problems are apparent, three categories of memory are tested: immediate recall, recent memory, and remote memory.

To assess immediate recall: Ask the client to repeat a series of three digits

– e.g. 7-4-3 – spoken slowly. Gradually increase the number of digits – e.g. -

7-4-3-5, 7-4-3-5-6, and 7-4-3-5-6-7-2 – until the client fails to repeat the series correctly.

Start again with a series of three digits, but this time, ask the client to repeat them backwards.

The average person can repeat a series of 5-8 digits in sequence, and 4-6 digits in reverse order.

To assess recent memory: Ask the client to recall the recent events of the

day, such as how he got to the clinic. This information must be validated, however.

Ask the client to recall information given early in the interview – e.g., the name of a doctor.

Provide the client with three facts to recall – e.g., a color, an object, an address, or a three-digit number – and ask the client to repeat all three. Later in the interview, ask the client to recall all three items.

To assess remote memory: Ask the client to describe a previous illness or

surgery.

Attention Span and Calculation

8. Test the ability to concentrate or attention span by asking the client to recite the alphabet or to count backward from 100.

Test the ability to calculate by asking the clients to subtract 7 or 3 progressively from 100 – i.e., 100, 93, 86, 79, or 100, 97, 94.

Level of Consciousness

9. Apply the Glasgow Coma Scale:Eye response, motor response, and verbal response.

Cranial Nerves

10. Test the cranial nerves.

Cranial Nerve I – OlfactoryAsk client to close eyes and identify different mild aromas such as coffee and vanilla.Cranial Nerve II – OpticAsk the client to read Snellen’s chart; check visual fields by confrontation, and conduct an ophthalmoscopic examination.Cranial Nerve III – OculomotorAssess six ocular movements and pupil reactionCranial Nerve IV – TrochlearAssess six ocular movements.Cranial Nerve V – TrigeminalWhile client looks upward, lightly touch the lateral sclera of the eye to elicit the blink reflex. To test light sensation, have the client close eyes, and wipe a wisp of cotton over client’s forehead and paranasal sinuses. To test deep sensation, use alternating blunt and sharp ends of a safety pin over the same area.Cranial Nerve VI – AbducensAssess directions of gaze.Cranial Nerve VII – FacialAsk the client to smile, raise the eyebrows, frown, puff out cheeks, and close eyes tightly. Ask the client to identify various tastes placed on the tip and sides of tongue – sugar, salt – and to identify areas of taste.Cranial Nerve VIII – AuditoryAssess the client’s ability to hear the spoken word and the vibrations of a tuning fork.Cranial Nerve IX – GlossopharyngealApply tastes on the posterior tongue for identification. Ask the client to move tongue from side to side and up and down.Cranial Nerve X – VagusAssessed with CN IX; assess the client’s speech for hoarseness.Cranial Nerve XI – AccessoryAsk the client to shrug shoulders against resistance

from your hands and to turn head to the side against resistance from your hand. Repeat for the other side.Cranial Nerve XII – HypoglossalAsk the client to protrude tongue at midline, then move it side to side.

Reflexes

11. Test reflexes using a percussion hammer, comparing one side of the body with other to evaluate the symmetry of response.Biceps ReflexThe biceps reflex tests the spinal cord levels C-5, C-6.Partially flex the client’s arm at the elbow, and rest the forearm over the thighs, placing the palm of the hand down.Place the thumb of your nondominant hand horizontally over the biceps tendon.Deliver a blow (slight downward thrust) with the percussion hammer to your thumb.Observe the normal slight flexion of the elbow, and feel the biceps’s contraction through your thumb.Triceps ReflexThe triceps reflex tests the spinal cord levels C-7, C-8Flex the client’s arm at the elbow, and support it in the palm of your nondominant hand.Palpate the triceps tendon about 2-5 cm (1-2 inches) above the elbow.Deliver a blow with the percussion hammer directly to the tendon.Observe for the normal slight extension of the elbow.

Brachioradialis ReflexThe brachioradialis reflex tests the spinal cord levels C-3, C-6Rest the client’s arm in a relaxed position on your forearm or on the client’s own leg.Deliver a blow with the percussion hammer directly on the radius 2-5cm (1-2inches) above the wrist or the styloid process, the bony prominence on the thumb side of the wrist.Observe the normal flexion and supination of the forearm. The fingers of the hand might also extend slightly.Patellar ReflexThe patellar reflex tests the spinal cord level L-2, L-3, L-4.Ask the client to sit on the edge of the examining table so that the legs hang freely.Locate the patellar tendon directly below the patella.

Deliver a blow with the percussion hammer directly to the tendon.Observe the normal extension or kicking out of the leg as the quadriceps muscle contracts.If no response occurs, and you suspect the client is not

relaxed, ask the client to interlock fingers and pull.Achilles ReflexThe Achilles reflex tests the spinal cord levels S-1, S-2.With the client in the same position as for the patellar reflex test, slightly dorsiflex the client’s ankle by supporting the foot lightly in your hand.Deliver a blow with the percussion hammer directly to the Achilles tendon just above the heel.Observe and feel the normal plantar flexion (downward jerk) of the foot.Plantar (Babinski’s) ReflexThe plantar or Babinski’s reflex is superficial. It might be absent in adults without pathology or overridden by voluntary control.Use a moderately sharp object such as the handle of the percussion hammer, a key, or the dull end of a pin or applicator stick.Stroke the lateral border of the sole of the client’s foot, starting at the heel, continuing to the ball of the foot, and then proceeding across the ball of the foot toward the big toe.Obeserve the response. Normally, all five toes bend downward; this reaction is negative Babinski’s. In an abnormal Babinski response, the toes spread outward and the big toe moves upward.

Motor Function

Assessment

12. Gross Motor and Balance Tests

Walking GaitAsk the client to walk across the room and back, and assess the client’s gait.Romberg’s TestAsk the client to stand with feet together and arms resting at the sides, first with eyes open, then closed.Standing On One Foot With Eyes ClosedAsk the client to close eyes and stand on one foot, then the other. Stand close to the client during this test.Heel-Toe WalkingAsk the client to walk a straight line, placing the heel of one foot directly in front of the toes of the other foot.Toe or Heel WalkingAsk the client to walk several steps on the toes and then on the heels.

13. Fine Motor Tests for the Upper Extremities

Finger-to-Nose TestAsk the client to abduct and extend arms at shoulder height and rapidly touch nose alternately with one

index finger and then the other. Have the client repeat the test with eyes closed if the test is performed easily.Alternating Supination and Pronation of Hands on KneesAsk the client to pat both knees with the palms of both hands and then with the backs of hands, alternately, at an ever-increasing rate.Finger to Nose and to the Nurse’s FingerAsk the client to touch nose and then your index finger, held at distance at about 45cm (18 inches), at a rapid and increasing rate.Fingers to FingersAsk the client to spread arms broadly at shoulder height and then bring fingers together at the midline, first with the eyes open and then closed, first slowly and then rapidly.Fingers to Thumb (Same Hand)Ask the client to touch each finger of one hand to the thumb of the same hand as rapidly as possible.

14. Fine Motor Tests for the Lower ExtremetiesAsk the client to lie supine and to perform these tests:Heel Down Opposite ShinAsk the client to place the heel of one foot just below the opposite knee and run the heel down the shin to foot. Repeat with the other foot. The client may also use a sitting position for this test. Toe or Ball of Foot to the Nurse’s FingerAsk the client to touch your finger with the large toe of each foot.

15. Light-Touch Sensation

Compare the light-touch sensation of symmetric areas of the body.Ask the client to close eyes and to respond by saying, “yes” or “now” whenever the client feels the cotton wisp touching the skin.With a wisp of cotton, lightly touch one specific spot and then the same spot on the other side of the body.Test areas on the forehead, cheek, hand, lower arm, abdomen, foot, and lower leg. Check a distal area of the limb first.Ask the client to point to the spot where the touch was felt.If areas of sensory dysfunction are found, determine the boundaries of sensation by testing responses approximately every 2.5cm (1inch) in the area. Make a sketch of the sensory loss area for recording purposes.

16. Pain Sensation

Assess pain sensation as follows:Ask the client to close his/her eyes and to say, “sharp,” “dull,” or “don’t know” when the sharp or dull end of

the broken tongue depressor is felt.Alternately, use the sharp and dull end of the sterile pin or needle to lightly prick designated anatomic areas at random. The face is not tested in this manner.Allow at least two seconds between each test.

17. Temperature Sensation

Touch skin areas with test tubes filled with hot or cold water.Have the client respond say saying, “hot,” “cold/” or “don’t know.”

18. Position or Kinesthetic Sensation

Commonly, the middle fingers and the large toes are tested for the kinesthetic sensation.To test the fingers, support the client’s arm with one hand and hold the client’s palm in the other. To test the toes, place the client’s heels on the examining table.Ask the client to close his/her eyes

Grasp a middle finger or a big toe firmly between your thumb and index finger, and exert the same pressure on both sides of the finger or toe while moving it.Move the finger or toe until it is up, down, or straight out, and ask the client to identify the position.Use a series of brisk up-and-down movements before bringing the finger or toe suddenly to rest in one of the three positions.

19. Tactile Discrimination

For all tests, the client’s eyes need to be closed.

One-and Two-Point DiscriminationAlternately stimulate the skin with two pins simultaneously and then with one pin. Ask whether the client feels one or two pinpricks.StereognosisPlace familiar objects – such as a key, paper clip, or coin – in the client’s hand, and ask the client to identify them.

If the client has a motor impairment of the hand and is unable to manipulate an object, write a number or letter on the client’s pal, using a blunt instrument, and ask the client to identify it.Extinction PhenomenonSimultaneously stimulate two symmetric areas of the body, such as thighs, the cheeks, or the hands.

20. Document findings in the client record

Self-evaluation:

Performing Urethral Urinary Catheterization

PreparationPerformed

Mastered CommentsYes No

1. Assess The client’s overall condition. If the client is able to cooperate and hold

still during the procedure. If the client can be positioned supine, with

head relatively flat. When the client last voided or was last

catheterizedPercuss the bladder to check for fullness or distension.

2. Determine: The most appropriate method of

catheterization.3. Assemble equipment and supplies:

Sterile catheter of appropriate size. An extra catheter should also be at hand.

Catheterization kit or individual sterile items: 1-2 pairs of sterile gloves Waterproof drape(s) Antiseptic solution Cleansing balls Forceps Water-soluble lubricant Urine receptacle Specimen container

For an indwelling catheter: Syringe prefilled with sterile water in amount specified by the catheter’s manufacturer Collection bag and tubing

2% Xylocaine gel (if agency permits) Disposable clean gloves Supplies for performing perineal cleansing. Bath blanket or sheet for draping the client Adequate lighting – obtain a flashlight or

lamp, if necessary.4. Perform routine perineal care to cleanse the

meatus from gross contamination.Procedure

1. Introduce yourself, and verify the client’s identity. Explain to the client what you are going to do, why it is necessary, and how the client can cooperate.

2. Perform hand hygiene, and observe other appropriate infection control procedures.

3. Provide for client privacy.

4. Place the client in the appropriate position, and drape all areas except the perinuim:Female: supine, with knees flexed, feet about 2 feet apart, and hips slightly externally rotated.Male: supine, legs slightly abducted

5. Establish adequate lighting. Stand on the client’s right if you are right-handed, on the client’s left if

you are left-handed.6. If using a collecting bag not contained within the

catheterization kit, open the drainage package, and place the end of the tubing within reach.

7. If agency policy permits, apply clean gloves, and inject 10-15mL Xylocaine gel into the urethra of the male client. Wipe the underside of the shaft to distribute the gel up the urethra. Wait at least 5 minutes for the gel to take effect before inserting the catheter. Remove gloves.

8. Open the catheterization kit. Place a waterproof drape under the buttocks (Female) or penis (male) without contaminating the center of the drape with your hands.

9. Apply sterile gloves.10. Organize the remaining supplies:

Saturate the cleansing balls with the antiseptic solution.Open the lubricant package.Remove the specimen container, and place it nearby, with the lid loosely on top.

11. Attach the prefilled syringe to the indwelling catheter inflation hub, and test the balloon.

12. Lubricate the catheter, and place it with the drainage end inside the collection container.

13. If desired, place the fenestrated drape over the perineum, exposing the urinary meatus.

14. Cleanse the meatus.Note: The nondominant hand is considered contaminated one it touches the client’s skin.

Female

Use your nondominant hand to spread the labia. Establish a firm but gentle position.Pick up a cleansing ball with the forceps in your dominant hand, and wipe one side of the labia majora in an anteroposterior direction.Use a new ball for the opposite side.Repeat for the labia minora.Use the last ball to cleanse directly over the meatus.

MaleUse your nondominant hand to grasp the penis just below the glans. If necessary, retract the foreskin. Hold the penis firmly upright, with slight tension.

Pick up a cleansing ball with the forceps in your dominant hand, and wipe from the center of the meatus in a circular motion around the glans.Use a new ball, and repeat three more times.

15. Insert the catheter.Grasp the catheter firmly 2-3 inches from the tip. Ask the client to take a slow deep breath, and

insert the catheter as the client exhales.Advance the catheter 2 inches further after urine begins to flow through it or per agency policy.If the catheter accidentally contacts the labia or slips into the vagina, it is considered contaminated, and a new, sterile catheter must be used. The contaminated catheter may be left in the vagina until the new catheter is inserted to help avoid mistaking the vaginal opening for the urethral meatus.

16. Hold the catheter with the nondominant hand. In males, lay the penis down onto the drape, being careful that the catheter does not pull out.

17. For an indwelling catheter, inflate the retention balloon with the designated volume.Without releasing the catheter, hold the inflation valve between two fingers of your nondominant hand while you attach the syringe (if not left attached earlier when testing the balloon), and inflate with your dominant hand.If the client complains of discomfort, immediately withdraw the instilled fluid, advance the catheter further, and attempt to inflate the balloon again.Pull gently on the catheter until resistance is felt to insure that the balloon has inflated and to place it in the trigone of the bladder.

18 Collect all urine specimen, if needed. Allow 20-30 mL to flow into the bottle without touching the catheter to the bottle.

19. Allow the straight catheter tp continue draining. if necessary, attach the drainage end of an indwelling catheter to the collecting tubing and bag.

20. Examine and measure the urine. In some cases, only 750-1000 mL of urine are to be drained from the bladder at one time. check agency policies.

21. Remove the straight catheter when urine flow stops.For an indwelling catheter, secure the catheter tubing to the inner thigh for female clients, or the upper thigh/abdomen for male clients, with enough slack to allow usual movement.Also secure the collecting tubing to the bed linens. and hang the bag below the level of the bladder. No tubing should fall below the top of the bag

22. Wipe the perineal area of any remaining antiseptic or lubrication. Replace foreskin, if retracted earlier. return the client to comfortable position.

23. Discard all used supplies in appropriate receptacles, and perform hand hygiene.

24. Document the catheterization procedure including catheter size and resukts in the client record

Self-evaluation: