Which instruction would the nurse give the patient to perform the Romberg test?
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The nervous system is a very complex system which is vital to the functioning of the human body. The nervous system is comprised of the central nervous system (CNS) and peripheral nervous system (PNS). There are 31 pairs of spinal nerves and 12 pairs of cranial nerves. Below are some tips for performing a Nursing Health Assessment of the Nervous System. For more information about performing a nursing health assessment read the article Tips for A Better Nursing Health Assessment. This will help you proceed through an assessment including the nervous system as you move from head-to-toe. This article contains 5 tips for Performing a Nursing Health Assessment of the Nervous System. Comprehensive Assessment of the Nervous System vs. A Hospital Recheck.A comprehensive or complete nursing health assessment of the nervous system is done when a neurological concern or dysfunction is suspected. A basic check or recheck of the nervous system can be done during a normal head-to-toe assessment. During a health assessment of the nervous system, you will assess the cranial nerves, motor function, sensory function, and reflexes. These tips cover all the basics for a comprehensive or complete nursing health assessment of the nervous system. You will use the techniques of observation, inspection, palpation and other techniques and methods to gather information about specific neurological functions. Tip #1 – Gather Information about the Patient’s History, Activities of Daily Living (ADLs) and Mental Status.Assess Patients history. This information will help guide your assessment.
Asses the patient’s ADL’s. Ask the following questions.
Observe the following
Assess the patient’s mental status.
Tip #2 – Gather Information on Chief Complaints or Symptoms.A nursing health assessment of the nervous system involves assessment of the chief complaint and common symptom. Common symptoms of the nervous system include headaches, dizziness, vertigo, generalized weakness, numbness, seizures, and tremors. HeadachesAssess for headaches out of the norm. For complaints of headaches, ask the patient the following question.
Dizziness and VertigoDistinguish between dizziness and vertigo. A patient experiencing dizziness may feel light-headed or faint. A patient experiencing vertigo will have the perception that the room is spinning. Ask the patient the following questions.
WeaknessWhen assessing weakness in a patient determine if it is generalized or localized. Distinguish between weakness and paralysis. Weakness is a problem or decreased ability to move a body part. Paralysis is a loss of motor function. For complaints of weakness, ask the patient the following question.
Numbness or tinglingParaesthesia is an abnormal sensation of burning and tingling. Ask the patient the following questions.
TremorsTremors are involuntary shaking or trembling of a body part. Ask the patient the following questions.
SeizuresA seizure is a disorder caused by a sudden excessive electrical discharge in the cerebral cortex. Attempt to get a complete description of the seizure activity. Ask the patient the following question.
Tip # 3 – Assessment of the Motor FunctionAssessment of motor function includes the neurological aspect of motor functions. These functions are directly related to the activity of the cerebellum. This includes coordination, smoothness of movement, and equilibrium. First, assess the patient’s gait and balance.
Next, perform the Romberg test.The Romberg test assesses equilibrium. For this test stand near the patient and be prepared to support them if they lose their balance.
Perform the finger to nose test.The finger to nose procedure test coordination and equilibrium. During this procedure, you are observing the movements of the arm. How smooth are the patient’s movements? What is the point of contact of the finger? Does the finger touch the nose, or is another part of the face touched?
Next, perform the rapid alternating movement test.The test assesses coordination. Observe the patient’s hands as they perform the procedure. Is the rhythm, continuous? Are the movements smooth or clumsy?
Next, perform the heel to shin test.During this procedure observe the smoothness of the action. The patient’s heel should follow a straight line and not fall off the leg.
Tip #4 – Assessment of the Sensory NervesThere are several sensations used to test the sensory system. The sensations which are used include pain, light touch, hot and cold, sharp and dull, and vibration, stereognosis, graphesthesia, and two-point discrimination. Assessing for pain.
Assess a patient’s ability to identify light touch.
Assess the patient’s ability to distinguish temperature.
Assess the patient’s ability to feel vibrations.
Test stereognosis.Sterognosis is the ability to identify an object without seeing it.
Test graphesthesia.Graphesthesia is the ability to perceive writing on the skin.
Perform the two-point discrimination test.This test assesses a patient’s ability to discriminate between two points.
Assess kinesthesia.Kinesthesia is a person’s ability to perceive the passive movement of the extremities.
Tip # 5 – Assess the ReflexesAssessment of the reflexes requires the use of a reflex hammer. Remember, that this is a complete neurological assessment. You will not see this done a lot in hospital settings. However, this is practiced in the nursing lab and usually makes great test questions. Some Practice is needed to properly handle the reflex hammer. When using the reflex hammer use just enough force to get a response. Compare the right and left sides. The responses should be equal. Grade the response on a 4-point scale listed below. Assess the biceps reflex.
Assess the triceps muscle reflex.
Assess the brachioradialis reflex.
Assess the quadriceps reflex.
Test the Achilles tendon reflex.
Assess plantar reflex.
Assess abdominal reflexes upper and lower.
In conclusion, the tips above will help you with a nursing health assessment of the nervous system. A comprehensive or complete nursing health assessment of the nervous system is done when a neurological concern or dysfunction is suspected. A basic check or recheck of the nervous system can be done during a normal head-to-toe assessment. Don’t forget to read the Assessment of the Cranial Nerves to complete the comprehensive nervous system assessment. Reference Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins. Disclaimer: The information contained on this site is not intended or implied to be a substitution for professional medical advice, diagnosis or treatment. All content, including text, graphics, images, and information, contained is provided for educational purposes only. You assume full responsibility for how you chose to use this information. Which instruction would the nurse give to a patient while performing the Romberg test quizlet?Which instruction would the nurse give to a patient while performing the Romberg test? "Stand with feet together and eyes open then closed." A positive Romberg sign is the loss of balance that occurs when closing the eyes. The nurse asks the patient to stand up with the feet together and arms at the sides.
Which test would the nurse perform to assess cerebellar function in a patient?Specific tests used to evaluate cerebellar function include assessment of gait and balance, pronator drift, the finger-to-nose test, rapid alternating action, and the heel-to-shin test.
Which assessment finding would the nurse document in the client's health record as a positive Romberg test?Which assessment finding would the nurse document in clients health record as positive Romberg test? inability to stand with feet together when eyes are closed *evaluates proprioception-client asked to close eyes when standing, if balance lost after eyes are closed a positive romberg test suggest theres sensory cause.
In which location would the nurse test a patient's superficial reflex?Plantar reflex is the only superficial reflex that's commonly assessed and should be tested in comatose patients, and those with suspected injury to lumbar 5-5 or sacral 1-2 areas of the spinal cord. Stimulate the sole of the foot with a tongue blade or the handle of a reflex hammer.
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