Procedure Checklist Chapter 19: Assessing The Sensory-Neurological System
Procedure Checklist Chapter 19: Assessing The Sensory-Neurological System
Procedure Checklist Chapter 19: Assessing The Sensory-Neurological System
Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing
focused, and appropriateness of responses.
9. Assesses abstract thinking, for example, by asking the
client to interpret a proverb, such as “A penny saved is a
penny earned.”
10. Assesses judgment by asking the client to respond to a
hypothetical situation, such as “If you were walking down
the street and saw smoke and flame coming from a house,
what would you do?”
11. Assesses communication ability.
a. During the exam, notes the rate, flow, choice of
vocabulary, and enunciation in client’s speech.
b. Tests spontaneous speech: Shows client a picture
and has him describe it.
c. Tests motor speech by having the client say “do, re,
mi, fa, so, la, ti, do.”
d. Tests automatic speech by having the client recite
the days of the week.
e. Tests sound recognition by having the client identify
a familiar sound, such as clapping hands.
f. Tests auditory-verbal comprehension by asking the
client to follow simple directions (e.g., point to your
nose, rub your left elbow).
g. Tests visual recognition by pointing to objects and
asking the client to identify them.
h. Tests visual-verbal comprehension by having the
client read a sentence and explain its meaning.
i. Tests writing by having the client write his name and
address.
j. Tests copying figures by having the client copy a
circle, x, square, triangle and star.
12. CN I–checks patency of nostrils, checks one nostril at a
time for client’s ability to identify the smell of common
substances.
13. CN II–tests visual acuity and visual fields; performs
fundoscopic exam.
14. CN III, IV, and VI–
a. Tests EOMs by having the client move the eyes
through the 6 cardinal fields of gaze with the head held
steady.
b. Tests pupillary reaction to light and
accommodation.
15. CN V, motor function–has client move his jaw from
side to side, clenching his jaw, and biting down on a tongue
blade.
16. CN V, sensory function–has the client close his eyes
and identify when nurse is touching his face at the
Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing
forehead, cheeks, and chin bilaterally—first with the finger
and then with a toothpick.
Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing
joint and having the patient identify when the vibration is
felt and when it stops.
29. Tests deep kinesthetic sensation (position sense) by
holding the client’s finger or toe on the sides and moving it
up or down. Instructs client to keep his eyes closed and
identify the direction of the movement.
30. Performs all discriminatory sensation tests:
stereognosis, graphesthesia, 2-point discrimination, point
localization, and sensory extinction.
31. Uses correct procedure to test discriminatory sensation
tests:
a. Assesses stereognosis by placing a familiar object
(e.g., a coin or a button) in the palm of the client’s hand
and having him identify it.
b. Assesses graphesthesia by drawing a number or
letter in the palm of patient’s hand and having the
patient identify what was drawn.
c. Tests 2-point discrimination with toothpicks. Has the
patient close his eyes. Touches him on the finger with 2
separate toothpicks simultaneously. Gradually moves
the points together and has the patient say “one” or
“two” each time the toothpicks are moved. Documents
distance and location at which he can no longer feel 2
separate points.
d. Tests point localization by having the patient close
his eyes while the nurse touches him. Have him point to
the area touched. Repeat on both sides and upper and
lower extremities.
e. Tests sensory extinction by simultaneously touching
the patient on both sides (e.g., on both hands, both
knees, both arms). Has the patient identify where he
was touched.
32. Tests each of the following deep tendon reflexes:
biceps, triceps, brachioradialis, patellar, and Achilles.
33. Uses correct procedure to test each reflex:
a. Biceps reflex (spinal cord level C–5 and C–6). Rests
the patient’s elbow in nondominant hand, with thumb
over the biceps tendon. Strikes the percussion hammer
to own thumb.
b. Triceps reflex (spinal cord level C–7 and C–8).
Abducts patient’s arm at the shoulder and flexes it at
the elbow. Supports the upper arm with nondominant
hand, letting the forearm hang loosely. Strikes the
triceps tendon about 1–2 inches (2.5 to 5 cm) above the
olecranon process.
c. Brachioradialis reflex (spinal cord level C–3 and C–
Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing
6). Rests patient’s arm on patient’s leg. Strikes with the
percussion hammer 1–2 inches (2.5 to 5 cm) above the
bony prominence of the wrist on the thumb side.
d. Patellar reflex (spinal cord level L–2, L–3, and L–
4). Has patient sit with legs dangling. Strikes the tendon
directly below the patella.
e. Achilles reflex (spinal cord level S–1, S–2). Has the
patient lie supine or sit with the legs dangling. Holds
the patient’s foot slightly dorsiflexed and strikes the
Achilles tendon about 2 inches (5 cm) above the heel
with the percussion hammer.
34. Uses the following scale to grade reflexes:
0 No response detected
+1 Diminished response
+2 Response normal
+3 Response somewhat stronger than normal
+4 Response hyperactive with clonus
35. Tests plantar superficial reflex with thumbnail or
pointed object. Strokes sole of foot in an arc from the
lateral heel to medially across the ball of the foot.
Student: Date:
Instructor: Date:
Copyright © 2007, F. A. Davis Company, Wilkinson & Van Leuven/Procedure Checklists for Fundamentals of Nursing