Neurological Assessment
Introduction
In order to provide the best care and plan the best treatment a thorough assessment must be undertaken. It is the most important step in the rehabilitation process, helps to guide our clinical reasoning and decision when making informed decisions about the rehabilitation process. Johnson & Thompson (1996) outlined that treatment can only be as good as the assessment on which it was based. So in order for us to progress and manage our treatment plan and ensure we are identifying out patients problems the assessment should be an ongoing and continuous process. A neurological assessment focuses on the nervous system to assess and identify any abnormalities that affect function and activities of daily living. It should allow us to create individual, patient-centred goals and ultimately a tailor-made treatment plan based on the client's needs.
Database
History of Present Condition
- Progression of the Condition
- Date of Onset of Signs & Symptoms
- Medical Management
- Medical Observations
- Other management
- Previous Therapy
- Results of Specific Investigations (X-rays, CT Scans, Blood Tests)
Past Medical History
- Co-morbidities and other non-related conditions
- Special Equipment, Technology Dependency
- Previous Surgery
- Medication History
Subjective Assessment
The subjective assessment is used to provide a detailed picture of how the present condition affects the patient.
Social History
- Social Situation
- Family Support
- Accommodation
- Social Service Support
Activity
- Normal Daily Routine
- Employment
- Leisure Activities
Mobility
- General
- Indoor
- Outdoor
- Steps & Stairs
- Falls
Personal Care
- Washing
- Continence
- Dressing
Other
- Vision
- Hearing
- Swallowing
- Fatigue
- Pain
- Perceptions of own Problems/Main Concern
- Expectations of Treatment
Objective Assessment
Posture and Balance
- Alignment
- Neglect
- Sitting Balance
- Standing Balance
Voluntary Movement
- Range of Movement
- Strength
- Endurance
- Coordination
Finger to Nose Test
Heel to Shin Test
Rapidly Alternating Movement
Involuntary Movement
- Tremor
- Clonus
- Chorea
- Associated Reactions
Tone
- Decreased / Flaccid
- Increased
Spasticity (Clasp-knife)
Rigidity (Cogwheel or Lead Pipe)
Reflexes
- Deep Tendon Reflexes
Biceps (C5/6)
Triceps (C7/8)
Knee (L3/4)
Ankle (S1/2) - Plantar Response (Babinski’s Sign)
Sensory
- Light Touch
- Pin Prick
- Two Point Discrimination
- Vibration Sense
- Joint Position Sense
- Temperature
- Vision and Hearing
Functional Activities
- Bed Mobility
- Sitting Balance
- Transfers
- Upper Limb Function
- Mobility
- Stairs
Gait
- Pattern
- Distance
- Velocity
- Use of Walking Aids
- Orthoses
- Assistance
- Cognitive Status
- Attention
- Orientation
- Memory
