121 Sensorimotor

Character

Description of the sign/symptom. How it looks, feels, sounds, smells

Onset

Where did it start

Location

Where it occurs, and/or radiates to

Duration

Length of time it lasts and if it recurs

Severity

How bad it is

Pattern

What improves or or makes it worse

Associated factors

Other symptoms occurring or aggravating factors

Symptoms of neurologic problems

Numbness, tingling, memory loss tremors, pain/headaches, seizures, comprehension, coordination, incontinence

Symptoms of head and neck problems

Difficulty moving, dizziness, lightheaded, loss of consciousness, spinning sensation

Head and neck treatment

Muscle relaxants, anticonvulsants, analgesics, vertebral, laminectomy, hematoma evacuation, physical therapy

Lifestyle leading to head, neck, neurological problems

Poor diet, peripheral neuropathy, smoking, improper body mechanics, repetitive motions

Symptoms of eye problems

Recent vision changes, spots, floaters, blind spots, halos, rings, night blindness, diplopia, pain, redness, swelling, discharge

Symptoms of ear problems

Sudden hearing changes, presbycussis, ear drainage, ear pain, tinnitus, vertigo

Lifestyle causing health and ear problems

Environmental, exposures: sun, loud noise, water

Current symptoms of musculoskeletal problems

Difficulty chewing, pain, altered mobility

Lifestyle affecting musculoskeletal problems

Medications, substance use, high amounts of purine, misuse of assisted devices, poor posture, can cause isolation if chronic

Objective head and neck neurological data

Inspect and palpate, LOC, cognition, mini mental exam tests, thought process, facial expressions, speech, mood, perceptions, mobility

LOC assessment

Always start with least noxious stimuli (verbal, tactile, painful)

Alert

Eyes opened, oriented x3, needs no further stimulation to stay awake

Lethargic

Opens eyes, answers questions, returns to sleep

Obtunded

Opens eyes to loud voice, respond slow w confusion, unaware of environment

Stupor

Awakens to vigorous shake or painful stimuli, returns to unresponsive sleep

Comatose

unresponsive to all stimuli, eyes remain closed

Glasgow coma scale

Objective neurological cranial and spinal nerves, inspect and palpate

12 cranial nerves, motor, sensory, cranial nerves can be motor, sensory, or both, mobility and balance, coordination, tactile, positions, reflexes

I olfactory

Function: smell, test: smell with eyes closed

II Optic

Function: visual acuity and field test: snellan chart, peripheral vision

III Oculomotor

Function: pupil reaction, test: pen light, perrla

IV Trochlear

Function: eye movement, test: following finger without moving head

V Trigeminal

Function: facial sensation, test:

VI abducens

Function: motor function, test: lateral eye function

VII Facial

Function: facial expressions, test: smile, wrinkle face, puff cheeks

VIII Acoustic

Function: hearing, balance, test: snap fingers, rhombergs test

IX Glossopharyngeal

Function: swallowing, voice, test: swallow, say “ahh”

X Vagus

Function: gag reflex, test: use tongue depressor

XI Spinal Accessory

Function: neck motion, test: shoulder shrugging

XII Hypoglossal

Function: tongue movement and strength, test: stick out tongue and apply resistance with tongue deep

Eye inspection

1. Assess eyelids and lashes for presence, width, redness, swelling, lesions, and discharge.

2. Note eyelid position relative to the eye.

3. Inspect conjunctiva and sclera with the client looking side to side, then up and down.

4. Conjunctiva: Should be clear, smooth, and moist (older adults may have yellow nodules).

5. Sclera: Should be white (may appear yellow in dark-skinned clients).

6. Assess palpebral conjunctiva by lowering it with thumbs; it should be clear.

Important to remember - ROM

Compare findings bilaterally, dominant side will be stronger, stop for pain, write the strength, do not force the body part beyond normal range

Tremors can be related to a

Neurological disorder

Enlarged head and facial bones can

Indicate presence of disease