Neurological Assessment: Difference between revisions
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<div class="editorbox"> '''Original Editor '''- [[User:User Name|Kim Jackson]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div> | <div class="editorbox"> '''Original Editor '''- [[User:User Name|Kim Jackson]] '''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}</div> | ||
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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<ref>Johnson J, Thompson AJ. Rehabilitation in a neuroscience centre: the role of expert assessment and selection. British Journal of Therapy and Rehabilitation. 1996 Jun;3(6):303-8.</ref>. 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. | 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<ref>Johnson J, Thompson AJ. Rehabilitation in a neuroscience centre: the role of expert assessment and selection. British Journal of Therapy and Rehabilitation. 1996 Jun;3(6):303-8.</ref>. 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. | ||
So for the proper neurological assessment, we can use a [[SOAP Notes|SOAP]] format as a guide. | |||
=== | == Subjective Assessment == | ||
The subjective assessment is used to provide a detailed picture of how the present condition affects the patient. | |||
=== Demographic Data === | |||
Name, Age, Gender, Occupation, Dominant hand, Address | |||
=== Chief Complain === | |||
What is his/her present complaint or problem for which they have visited you? | |||
=== History of Present Condition === | |||
*Progression of the Condition | *Progression of the Condition | ||
*Date of Onset of Signs & Symptoms | *Date of Onset of Signs & Symptoms | ||
| Line 24: | Line 32: | ||
*Previous Surgery | *Previous Surgery | ||
*Medication History | *Medication History | ||
*History of any allergies | |||
== | === Personal History === | ||
Marital status, occupation, | |||
Activity | |||
*Normal Daily Routine | *Normal Daily Routine | ||
*Employment | *Employment | ||
*Leisure Activities | *Leisure Activities | ||
*Smoking and drinking habits | |||
Mobility | |||
*General | *General | ||
*Indoor | *Indoor | ||
| Line 49: | Line 48: | ||
*Steps & Stairs | *Steps & Stairs | ||
*Falls | *Falls | ||
Personal Care | |||
*Washing | *Washing | ||
*Continence | *Continence | ||
*Dressing | *Dressing | ||
Other | |||
*Vision | *Vision | ||
*Hearing | *Hearing | ||
| Line 65: | Line 60: | ||
*Perceptions of own Problems/Main Concern | *Perceptions of own Problems/Main Concern | ||
*Expectations of Treatment | *Expectations of Treatment | ||
=== Family History === | |||
Total number of family members, his/her primary caretaker, | |||
=== Socioeconomic History === | |||
* Family income source | |||
* Relationship with community people | |||
* Social Situation | |||
*Family Support | |||
*Accommodation | |||
*Social Service Support | |||
== Objective Assessment == | == Objective Assessment == | ||
=== | === On Observation === | ||
# Built | |||
*Alignment | # Gait | ||
# Pattern of Movement | |||
# Mode of Ventilation | |||
# Type/ Pattern of Respiration | |||
# Oedema | |||
# Muscle Wasting | |||
# Pressure Sores | |||
# Deformity | |||
# Wounds | |||
# External Appliances | |||
# Posture and Balance | |||
*Alignment and attitude of limbs | |||
*Neglect | *Neglect | ||
*Sitting Balance | *Sitting Balance | ||
*Standing Balance<br> | *Standing Balance<br> | ||
=== Vital Signs === | |||
Respiratory rate | |||
Temperature | |||
Pulse rate | |||
Blood pressure | |||
O2 saturation | |||
=== On Examination === | |||
==== Higher mental function ==== | |||
===== Level of consciousness: [[Glasgow Coma Scale|Glasscow coma scale (GCS)]] ===== | |||
* | |||
===== Communication: ===== | |||
Aphasia ( Broca's, Wernicke's, Global) | |||
===== Cognition: ===== | |||
* Orientation: | |||
** Person: | |||
** Place: | |||
** Time: | |||
* Calculation: | |||
* Registration: | |||
* Attention: | |||
* Proverb Interpretation: | |||
* Memory: | |||
** Immediate: | |||
** Recent: | |||
** Remote: | |||
** Verbal: | |||
** Visual: | |||
* Language | |||
* Visuospatial proficiency | |||
There are various outcome tools via which we can address his/her cognitive status incorporating various components. | |||
* [[Mini-Mental State Examination|Mini-mental Status Examination]] | |||
* [[Mini-cog]] | |||
* [[Montreal cognitive assessment (MoCA)]] | |||
===== Perception: ===== | |||
* Body Scheme/ Body Imaging | |||
* Agnosias/ Apraxias: | |||
Common tools to assess perceptual problems are: | |||
* Star Cancellation Test. | |||
* Line Bisection Test. | |||
* Clock Drawing Test. | |||
=== Voluntary Movement === | === Voluntary Movement === | ||
| Line 133: | Line 201: | ||
==References== | ==References== | ||
<references/> | <references /> | ||
[[Category:Neurology]] | [[Category:Neurology]] | ||
[[Category:Neurological - Assessment and Examination]] | [[Category:Neurological - Assessment and Examination]] | ||
Revision as of 07:24, 3 April 2021
Original Editor - Kim Jackson Top Contributors - Manisha Shrestha, Kim Jackson, Shaimaa Eldib, Kirenga Bamurange Liliane, Admin, Rucha Gadgil and Kanzaa Rahim
Introduction[edit | edit source]
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[1]. 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.
So for the proper neurological assessment, we can use a SOAP format as a guide.
Subjective Assessment[edit | edit source]
The subjective assessment is used to provide a detailed picture of how the present condition affects the patient.
Demographic Data[edit | edit source]
Name, Age, Gender, Occupation, Dominant hand, Address
Chief Complain[edit | edit source]
What is his/her present complaint or problem for which they have visited you?
History of Present Condition[edit | edit source]
- 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 [edit | edit source]
- Co-morbidities and other non-related conditions
- Special Equipment, Technology Dependency
- Previous Surgery
- Medication History
- History of any allergies
Personal History[edit | edit source]
Marital status, occupation,
Activity
- Normal Daily Routine
- Employment
- Leisure Activities
- Smoking and drinking habits
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
Family History[edit | edit source]
Total number of family members, his/her primary caretaker,
Socioeconomic History[edit | edit source]
- Family income source
- Relationship with community people
- Social Situation
- Family Support
- Accommodation
- Social Service Support
Objective Assessment[edit | edit source]
On Observation[edit | edit source]
- Built
- Gait
- Pattern of Movement
- Mode of Ventilation
- Type/ Pattern of Respiration
- Oedema
- Muscle Wasting
- Pressure Sores
- Deformity
- Wounds
- External Appliances
- Posture and Balance
- Alignment and attitude of limbs
- Neglect
- Sitting Balance
- Standing Balance
Vital Signs[edit | edit source]
Respiratory rate
Temperature
Pulse rate
Blood pressure
O2 saturation
On Examination[edit | edit source]
Higher mental function[edit | edit source]
Level of consciousness: Glasscow coma scale (GCS)[edit | edit source]
Communication:[edit | edit source]
Aphasia ( Broca's, Wernicke's, Global)
Cognition:[edit | edit source]
- Orientation:
- Person:
- Place:
- Time:
- Calculation:
- Registration:
- Attention:
- Proverb Interpretation:
- Memory:
- Immediate:
- Recent:
- Remote:
- Verbal:
- Visual:
- Language
- Visuospatial proficiency
There are various outcome tools via which we can address his/her cognitive status incorporating various components.
Perception:[edit | edit source]
- Body Scheme/ Body Imaging
- Agnosias/ Apraxias:
Common tools to assess perceptual problems are:
- Star Cancellation Test.
- Line Bisection Test.
- Clock Drawing Test.
Voluntary Movement[edit | edit source]
- Range of Movement
- Strength
- Endurance
- Coordination
Finger to Nose Test
Heel to Shin Test
Rapidly Alternating Movement
Involuntary Movement[edit | edit source]
- Tremor
- Clonus
- Chorea
- Associated Reactions
Tone[edit | edit source]
- Decreased / Flaccid
- Increased
Spasticity (Clasp-knife)
Rigidity (Cogwheel or Lead Pipe)
Reflexes[edit | edit source]
- Deep Tendon Reflexes
Biceps (C5/6)
Triceps (C7/8)
Knee (L3/4)
Ankle (S1/2) - Plantar Response (Babinski’s Sign)
Babinski Sign Test video provided by Clinically Relevant
Sensory[edit | edit source]
- Light Touch
- Pin Prick
- Two Point Discrimination
- Vibration Sense
- Joint Position Sense
- Temperature
- Vision and Hearing
Functional Activities[edit | edit source]
- Bed Mobility
- Sitting Balance
- Transfers
- Upper Limb Function
- Mobility
- Stairs
Gait[edit | edit source]
- Pattern
- Distance
- Velocity
- Use of Walking Aids
- Orthoses
- Assistance
- Cognitive Status
- Attention
- Orientation
- Memory
References[edit | edit source]
- ↑ Johnson J, Thompson AJ. Rehabilitation in a neuroscience centre: the role of expert assessment and selection. British Journal of Therapy and Rehabilitation. 1996 Jun;3(6):303-8.
