BUKIDNON STATE UNIVERSITY

COLLEGE OF NURSING
Health Assessment RLE

Date Performed: Final Grade:

Clinical Instructor:

Assessing the General Appearance, Mental status, and Neurological System

Definition:

Objectives:
1.

2.

3.
Safety/Security Measures:
1.

2.

3.
Pre-procedural Preparations:
1. Wash hands
2. Introduce yourself to the client and identify client’s identity. Explain what you are going to
do, why it is necessary, and how the client can cooperate.
3. Gather the necessary equipment.
4. Provide Privacy
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 Able to Unable to

perform perform

1.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
 Problems with smell, vision, taste, touch, or hearing
 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

Assessing the General Appearance and Mental Status

 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
2. Observe body build, height, and weight in relation to the client’s age,
lifestyle, and health.
3. Observe the client’s posture and gait, standing, sitting, and walking.
4. Observe the client’s overall hygiene and grooming. Relate these to the
person’s activities prior to the assessment.
5. Note body and breath odor in relation to activity level.
6. Observe for signs of distress in posture or facial expression.
7. Note obvious signs of health or illness.
8. Assess the client’s attitude.
9. Note the client’s affect/mood; assess the appropriateness of the client’s
responses.
10. Listen for quantity, quality, and organization of speech.
11. Listen for relevance and organization of thoughts.

Language
12. If the client displays difficulty speaking:
13.Point to common objects, and ask the client to name them.
14.Ask the client to read some words and to match the printed and written
words with pictures.
15.Ask the client to respond to simple verbal and written commands—e.g.,
“Point to your toes” or “Raise your left arm.”

Orientation
16. Determine the client’s orientation to time, place, and person by tactful
questioning.
17.Ask the client the city and state of residence, time of day, date, day of
the week, duration of illness, and names of family members.
18.More direct questioning might be necessary for some people—e.g.,
“Where are you now?” “What day is it today?”

Memory
19. Listen for lapses in memory.
20.Ask the client about difficulty with memory. If problems are apparent,
three categories of memory are tested: immediate recall, recent memory,
and remote memory.
21.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 backward.

>The average person can repeat a series of 5–8 digits in sequence, and 4–6
digits in reverse order.
 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
23.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.
24. To assess remote memory:

>Ask the client to describe a previous illness or surgery.

Attention Span and Calculation
25. Test the ability to concentrate or attention span by asking the client to recite
the alphabet or to count backward from 100.
26.Test the ability to calculate by asking the client to subtract 7 or 3
progressively from 100—i.e., 100, 93, 86, 79, or 100, 97, 94.
Level of Consciousness
27. Apply the Glasgow Coma Scale:
Eye response, motor response and verbal response
Cranial Nerves
28. Cranial Nerve I—Olfactory
Ask client to close eyes and identify different mild aromas, such as coffee
and vanilla.
29. Cranial Nerve II—Optic
Ask the client to read Snellen’s chart; check visual fields by confrontation,
and conduct an ophthalmoscopic examination.
30. Cranial Nerve III—Oculomotor
Assess six ocular movements and pupil reaction.
31. Cranial Nerve IV—Trochlear
Assess six ocular movements.
32. Cranial Nerve V—Trigeminal
While 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 same
area.
33. Cranial Nerve VI—Abducens
Assess directions of gaze.
34. Cranial Nerve VII—Facial
Ask 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.
35. Cranial Nerve VIII—Auditory
Assess the client’s ability to hear the spoken word and the vibrations of a
tuning fork.
36. Cranial Nerve IX—Glossopharyngeal
Apply tastes on the posterior tongue for identification. Ask the client to
move tongue from side to side and up and down.
37. Cranial Nerve X—Vagus
Assessed with CN IX; assess the client’s speech for hoarseness.
 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
38. Cranial Nerve XI—Accessory
Ask 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.
39. Cranial Nerve XII—Hypoglossal
Ask the client to protrude tongue at midline, then move it side to side.

Reflexes
40. Test reflexes using a percussion hammer, comparing one side of the
body with the other to evaluate the symmetry of response.
41. Biceps Reflex
The biceps reflex tests the spinal cord level C-5, C-6.
42.Partially flex the client’s arm at the elbow, and rest the forearm over the
thighs, placing the palm of the hand down.
43.Place the thumb of your nondominant hand horizontally over the biceps
tendon.
44.Deliver a blow (slight downward thrust) with the percussion hammer to
your thumb.
45.Observe the normal slight flexion of the elbow, and feel the biceps’s
contraction through your thumb.
46. Triceps Reflex
The triceps reflex tests the spinal cord level C-7, C-8.
47.Flex the client’s arm at the elbow, and support it in the palm of your
nondominant hand.
48.Palpate the triceps tendon about 2–5 cm (1–2 inches) above the elbow.
49.Deliver a blow with the percussion hammer directly to the tendon.
50.Observe for the normal slight extension of the elbow.
51. Brachioradialis Reflex
The brachioradialis reflex tests
the spinal cord level C-3, C-6.
52.Rest the client’s arm in a relaxed position on your forearm or on the
client’s own leg.
53.Deliver a blow with the percussion hammer directly on the radius 2–5
cm (1–2 inches) above the wrist or the styloid process, the bony
prominence on the thumb side of the wrist.
54.Observe the normal flexion and supination of the forearm. The fingers of
the hand might also extend slightly.
55. Patellar Reflex
The patellar reflex tests the spinal cord level L-2. L-3, L-4.
56.Ask the client to sit on the edge of the examining table so that legs hang
freely.
57.Locate the patellar tendon directly below the patella.
58.Deliver a blow with the percussion hammer directly to the tendon.
59.Observe the normal extension or kicking out of the leg as the quadriceps
muscle contracts.
60.If no response occurs, and you suspect the client is not relaxed, ask the
client to interlock fingers and pull.
61. Achilles Reflex
The Achilles reflex tests the spinal cord level S-1, S-2.
62.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.
63.Deliver a blow with the percussion hammer directly to the Achilles
tendon just above the heel.
 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
64.Observe and feel the normal plantar flexion (downward jerk) of the foot.
65. Plantar (Babinski’s) Reflex
The plantar or Babinski’s reflex is superficial. It might be absent in adults
without pathology, or overridden by voluntary control.
66.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.
67.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.
68.Observe 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
69. Gross Motor and Balance Tests
70.Walking Gait
Ask the client to walk across the room and back, and assess the client’s
gait.
71.Romberg’s Test
Ask the client to stand with feet together and arms resting at the sides, first
with eyes open, then closed.
72.Standing On One Foot With Eyes Closed
Ask the client to close eyes and stand on one foot, then the other. Stand
close to the client during this test.
73.Heel–Toe Walking
Ask the client to walk a straight line, placing the heel of one foot directly in
front of the toes of the other foot.
74.Toe or Heel Walking
Ask the client to walk several steps on the toes and then on the heels.
75. Fine Motor Tests for the Upper Extremities
76.Finger-to-Nose Test
Ask 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.
77.Alternating Supination and Pronation of Hands on Knees
Ask 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.
78.Finger to Nose and to the Nurse’s Finger
Ask the client to touch nose and then your index finger, held at a distance at
about 45 cm (18 inches), at a rapid and increasing rate.
79.Fingers to Fingers
Ask the client to spread arms broadly at shoulder height and then bring
fingers together at the midline, first with eyes open and then closed, first
slowly and then rapidly.
80.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.
81. Fine Motor Tests for the Lower Extremities
Ask the client to lie supine and to perform these tests:
 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
82.Heel Down Opposite Shin
Ask 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.
83.Toe or Ball of Foot to the Nurse’s Finger
Ask the client to touch your finger with the large toe of each foot.
84. Light-Touch Sensation
85.Compare the light-touch sensation of symmetric areas of the body.
86.Ask the client to close eyes and to respond by saying “yes” or “now”
whenever the client feels the cotton wisp touching skin.
87.With a wisp of cotton, lightly touch one specific spot and then the same
spot on the other side of the body.
88.Test areas on the forehead, cheek, hand, lower arm, abdomen, foot, and
lower leg. Check a distal area of the limb first.
89.Ask the client to point to the spot where the touch was felt.
90.If areas of sensory dysfunction are found, determine the boundaries of
sensation by testing responses approximately every 2.5 cm (1 inch) in the
area. Make a sketch of the sensory loss area for recording purposes.
91. Pain Sensation
92.Assess pain sensation as follows:
Ask the client to close his eyes and to say “sharp,” “dull,” or “don’t know”
when the sharp or dull end of the broken tongue depressor is felt.
93.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.
94.Allow at least two seconds between each test.
95. Temperature Sensation
96.Touch skin areas with test tubes filled with hot or cold water.
97.Have the client respond say saying “hot,” “cold,” or “don’t know.”
98. Position or Kinesthetic Sensation
99.Commonly, the middle fingers and the large toes are tested for the
kinesthetic sensation.
100.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.
101.Ask the client to close eyes.
102.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.
103.Move the finger or toe until it is up, down, or straight out, and ask the
client to identify the position.
104.Use a series of brisk up-and-down movements before bringing the
finger or toe suddenly to rest in one of the three positions.
105. Tactile Discrimination
106.For all tests, the client’s eyes need to be closed:
107.One- and Two-Point Discrimination
Alternately stimulate the skin with two pins simultaneously and then with
one pin. Ask whether the client feels one or two pinpricks.
 BUKIDNON STATE UNIVERSITY
COLLEGE OF NURSING
Health Assessment RLE
108.Stereognosis
Place familiar objects—such as a key, paper clip, or coin—in the client’s
hand, and ask the client to identify them.

109.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 palm, using a
blunt instrument, and ask the client to identify it.
110. Extinction Phenomenon Simultaneously stimulate two symmetric areas of
the body, such as the thighs, the cheeks, or the hands.
111. Document findings in the client record.
112. Ability to Answer questions
113. Definition
114. Objectives
115. Safety/Security measures
Total score
Equivalent grade

Remarks:
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Name and Signature of Instructor:

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