NURS 258 Lecture Notes - Lecture 13: Start Ii, Dysphagia, Congenital Disorder
258 Neurological System Outline
1. Subjective Data
a. Headache: Have you had any unusually frequent or severe headaches? When did this
start? How often does it occur? Where in your head does it hurt? What relieves it?
b. Head injury: Have you ever had any head injury? What part of the head was injured?
Describe. 1st Did you lose consciousness – may indicate brain injury
c. Dizziness: Do you ever feel lightheaded, swimming sensation, like feeling faint.
d. Vertigo: Do you ever feel a sensation called vertigo, a rotational spinning sensation.
Does it come on gradual or rapidly?
e. Seizures: Have you ever had any convulsions. When did they start? How often do they
occur? When seizures activity starts, do you have warning signs?
i. Course Duration - when did they start
ii. Motor activity – where in your body does it occur
iii. Associated signs – color changes to face/lips, incontinent
iv. Precipitating factors – what brings it on
v. Coping strategies – has it affected daily life, effected occupation
f. Tremors Any shakiness? When/how? What relieves it?
g. Weakness: Is this generalized or local? Does weakness occur with particular movement?
h. Incoordination Do you have any problem with coordination (walking/balance/legs giving
way/falls)?
i. Numbness or tingling – pins and needles? Where? Is it worse/better with activity?
j. Difficulty swallowing trouble swallowing? Solids/liquids?
k. Difficulty speaking when did it start? How long did it last?
l. Patient Centered Care (history) head injury/spinal cord injury, family history of strokes,
congenital defect, alcohol
m. Environmental and occupational hazards?: Are you exposed to insecticides, organic
solvents, or lead? Pollution, second hand smoke, medication, mood altering drug,
alcohol – how much/often
n. Any problems with:
i. Attention span
ii. Memory
iii. Reasoning
o. Children- Are they meeting developmental milestones Make sure to ask the parent if
they are reaching their milestones
i. Head control
ii. Motor development: assess play
iii. Sensory system rarely assessed until 7-9 months
iv. Babinski reflex
1. Infants fan toes
2. Adults flex toes and forefoot
p. Additional History for aging adult
i. Any problem with dizziness?
1. Does it occur when you first sit or stand up, when you move your head,
get up and walk, or after eating? Does it occur with any medications?
2. (For men) Do you ever get up at night and feel faint while standing to
urinate?
3. How does dizziness affect your daily activities? Are you able to drive
safely and maneuver within your house safely?
4. What safety modifications have you applied at home?
5. Have you noticed a decrease in memory or a change in mental function?
Have you felt any confusion? Does it come on suddenly or gradually?
6. Have you noticed any tremor in hands or face? Is it worse with anxiety,
activity, or rest? Does it seem to be relieved with alcohol, activity, or
rest? Does it interfere with daily or social activities?
7. Have you had any sudden vision changes or fleeting blindness? Did this
occur along with weakness? Did you have any loss of consciousness?
2. Objective Data
a. Mental Status exam
i. Consciousness – did they lose consciousness
1. Most
a. Awareness of environment, feelings, and thought
b. Levels of consciousness
ii. Awareness
iii. Levels
iv. Alert
1. AAOx3
v. Lethargic
1. Not fully alert, drifts off easy
