Tina Jones Neurological shadow health assessment Objective Data

Tina Jones Neurological shadow health assessment Objective Data

Tina Jones Neurological shadow health assessment Objective Data

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Tina Jones Neurological shadow health assessment Objective Data

Objective Data Collection: 36.75 of 37 (99.32%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed

 Confirmed orientation
1 of 1 point

To Person (1/3 point)

  •  Oriented to person
  •  Not oriented to person

To Place (1/3 point)

  •  Oriented to place
  •  Not oriented to place

To Time (1/3 point)

  •  Oriented to time
  •  Not oriented to time

 Evaluated abstract thinking
1 of 1 point

Abstractness (1/2 point)

  •  Abstract
  •  Concrete

Relevance (1/2 point)

  •  Relevant
  •  Not relevant

 Evaluated attention span
1 of 1 point

Serial 7s Test (1/1 point)

  •  Accurate
  •  Not accurate

 Evaluated comprehension
1 of 1 point

Observations (1/1 point)

  •  Able to follow instructions
  •  Unable to follow instructions

 Evaluated general knowledge
1 of 1 point

Accuracy (1/1 point)

  •  Accurate
  •  Not accurate

 Evaluated judgment
1 of 1 point

Observations (1/1 point)

  •  Intact
  •  Not intact

 Evaluated memory
1 of 1 point

Remote Memory (1/3 point)

  •  Intact
  •  Not intact

Immediate Memory (1/3 point)

  •  Intact
  •  Not intact

New Learning Ability (1/3 point)

  •  Accurate
  •  Not accurate

 Observed vocabulary
1 of 1 point

Complexity (1/1 point)

  •  Expected complex for patient’s age, education level, and general ability
  •  Not expected complexity
  • Tina Jones Neurological shadow health assessment Objective Data

 Observed articulation
1 of 1 point

Observations (1/1 point)

  •  No observed problems with pronunciation or expression
  •  Imprecise pronunciation of consonants
  •  Slurring
  •  Hesitation
  •  Stutter

 Tested olfactory nerve
1 of 1 point

Sense Of Smell (1/2 point)

  •  Able to discriminate
  •  Not able to discriminate

Symmetric (1/2 point)

  •  Symmetric bilaterally
  •  Asymmetric

 Tested visual acuity (optic nerve)
1 of 1 point

Right (1/2 point)

  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10

Left (1/2 point)

  •  20/100
  •  20/70
  •  20/50
  •  20/40
  •  20/30
  •  20/25
  •  20/20
  •  20/15
  •  20/13
  •  20/10

 Examined retina with ophthalmoscope (optic nerve)
0.75 of 1 point

Right: Fundus (No point)

  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage

Right: Disc Margin (1/4 point)

  •  Sharp
  •  Blurred

Left: Fundus (1/4 point)

  •  No visible abnormal findings
  •  Myelinated nerve fibers
  •  Papilledema
  •  Glaucomatous cupping
  •  Drusen bodies
  •  Cotton wool bodies
  •  Hemorrhage

Left: Disc Margin (1/4 point)

  •  Sharp
  •  Blurred

 Inspected pupils (optic and oculomotor nerves)
1 of 1 point

Observations With Penlight (1/1 point)

  •  No visible abnormal findings (PERRL)
  •  Unequal
  •  Irregular
  •  Miosis
  •  Mydriasis
  •  Non-reactive to light

 Tested extraocular eye movements (extraocular movements: oculomotor, trochlear, abducens nerves)
1 of 1 point

Cardinal Fields (1/2 point)

  •  No visible abnormal findings
  •  Nystagmus
  •  Fixed pupil

Convergence (1/2 point)

  •  No visible abnormal findings
  •  Unequal bilaterally
  •  Fixed pupil

 Tested facial sensation (trigeminal nerve)
1 of 1 point

Observations (1/1 point)

  •  Intact
  •  Unable to feel dull stimulus
  •  Unable to feel sharp stimulus
  •  Unable to feel soft stimulus

 Inspected head and face (facial nerve)
1 of 1 point

Skull Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Facial Feature Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

 Performed Weber test (auditory nerve)
1 of 1 point

Results (1/1 point)

  •  Normal
  •  Conductive or sensorineural loss

 Performed Rinne test (auditory nerve)
1 of 1 point

Right (1/2 point)

  •  Normal
  •  Conductive loss

Left (1/2 point)

  •  Normal
  •  Conductive loss

 Tested gag reflex (glossopharyngeal, vagus nerves)
1 of 1 point

Observations (1/1 point)

  •  Intact
  •  Absent
  •  Hypersensitive

 Tested shoulder shrugging (accessory nerve)
1 of 1 point

Observations (1/2 point)

  •  Symmetric
  •  Asymmetric

Strength (1/2 point)

  •  0 – No evidence of movement
  •  1 – Trace of movement
  •  2 – Full range of motion with passive movement only
  •  3 – Full range of motion against gravity, with no resistance
  •  4 – Full but weak range of motion against gravity, with some resistance
  •  5 – Full range of motion against gravity, with resistance
  • Tina Jones Neurological shadow health assessment Objective Data

 Tested neck strength (accessory nerve)
1 of 1 point

Strength (1/1 point)

  •  0 – No evidence of movement
  •  1 – Trace of movement
  •  2 – Full range of motion with passive movement only
  •  3 – Full range of motion against gravity, with no resistance
  •  4 – Full but weak range of motion against gravity, with some resistance
  •  5 – Full range of motion against gravity, with resistance

 Inspected tongue (hypoglossal nerve)
1 of 1 point

Symmetry (1/2 point)

  •  Symmetric
  •  Asymmetric

Observations (1/2 point)

  •  No visible abnormal findings
  •  Fasciculations
  •  Deviation from midline
  •  Atrophy

 Tested deep tendon reflexes in triceps
1 of 1 point

Right (1/2 point)

  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus

Left (1/2 point)

  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus

 Tested deep tendon reflexes in biceps
1 of 1 point

Right (1/2 point)

  •  0 – No response
  •  1 – Diminished
  •  2 – Expected (active)
  •  3 – Hyperactive
  •  4 – Hyperactive, with clonus

Left (1/2 point)</strong

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