Cheap essays, research papers, dissertations.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)
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CHAT US TO PLACE OUR ORDER AND SCORE 100%
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)
0 – No response
1 – Diminished
2 – Expected (active)
3 – Hyperactive
4 – Hyperactive, with clonus
Tested deep tendon reflexes in brachioradialis
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 patellar tendon
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 Achilles tendon
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 point-to-point movements: Finger to nose
1 of 1 point
Right (1/2 point)
Smooth and accurate
Jerky
Inaccurate
Left (1/2 point)
Smooth and accurate
Jerky
Inaccurate
Tested point-to-point movements: Heel to shin
1 of 1 point
Right (1/2 point)
Smooth and accurate
Jerky
Inaccurate
Left (1/2 point)
Smooth and accurate
Jerky
Inaccurate
Tested coordination with rapid alternating hand movements
1 of 1 point
Observations (1/1 point)
Able to perform without difficulty
Performs but with difficulty
Unable to perform
Observed gait
1 of 1 point
Balance (1/2 point)
Steady
Unsteady
Gait (1/2 point)
Continuous, symmetric steps
Discontinuous steps
Asymmetric steps
Stagger
Swaying
Hesitancy due to injury
Use of arms
Tested graphesthesia
1 of 1 point
Right (1/2 point)
Able to identify
Unable to identify
Left (1/2 point)
Able to identify
Unable to identify
Tested sensation in arms
1 of 1 point
Right: Dull Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Left: Dull Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Tina Jones Neurological shadow health assessment Objective Data
Right: Soft Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Left: Soft Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Right: Sharp Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Left: Sharp Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Tested sensation in legs
1 of 1 point
Right: Dull Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Tina Jones Neurological shadow health assessment Objective Data
Left: Dull Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Right: Soft Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Left: Soft Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Right: Sharp Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Left: Sharp Touch (1/6 point)
Expected sensation in proximal and distal
Decreased proximal sensation
Decreased distal sensation
Tested sensation in feet
1 of 1 point
Right (1/2 point)
Expected sensation
Decreased sensation
Left (1/2 point)
Expected sensation
Decreased sensation
Tested position sense
1 of 1 point
Fingers (1/2 point)
Intact
Not intact
Toes (1/2 point)
Intact
Not intact
Tested stereognosis
1 of 1 point
Right (1/2 point)
Able to identify
Unable to identify
Left (1/2 point)
Able to identify
Unable to identify
Tina Jones Neurological shadow health assessment Objective Data
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