Neurological Assessment SOAP note APA PDF

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soap note assessment of the neurological system . includes subjective-objective data , assessment and plan for this neurological assessment...

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Neurological Assessment Payton Santana Rasmussen College NUR2180:Physical Assessment Amanda Alexander, RN November 21, 2021

2 Subjective Information Client is a 26-year-old male who presents today with a migraine that has been consistent for 3 days. Client currently works at the county jail overnight and works 12 hour shifts three to four times a week. He also complains of some stiffness in his neck after sleeping. He noticed the migraine three days ago and it started out as a small headache, when it didn’t go away, he tried to take Tylenol and Ibuprofen the next day, with the headache increasing. Client states he does not get headaches very often, so when it did not go away after self-medication, he decided to seek external help. The client states the migraine is located around the entire front of his head as well as the base of his skull. Client rates the pain a consistent 8/10 with 10 being the worst pain he has felt. He describes the pain as a sharp pulsating pain that occasionally stops for a few minutes, but then continues when he tries to move or perform strenuous activity. He reports some dizziness when standing up. He cannot go outside without sunglasses due to light sensitivity. A warm compress on the top of his head does provide a slight relief. Client states he has no previous neurological history or damage to himself or in his family. He denies any jaw pain or facial pain. He also denies any radiating pain to any location on his body. Client has no know allergies and only take multivitamins daily. Client states he only drinks socially. He is able to keep small meals and liquids down, and feels that he really just needs to sleep.

Objective information Clients vital signs read as follows- Blood Pressure: 117/70, Heart rate: 60, Resp: 20, O2 98. He is alert to person, place, and time. Client does not appear to have any speech impediments and is able to repeat words correctly. Client does have some photosensitivity but denies diplopia now and previously. Test on the olfactory nerve (CNI) is intact, client can smell alcohol wipe.

3 Visual acuity – optic nerve (CNII), extraocular eye movements (CNIII,-oculomotor, CNIVtrochlear, and CNVI-adducens nerves) are all intact. This was tested by the six cardinal directions of gaze. Client is able to feel sensations on face, bilateral upper and lower extremities. He can clench his jaw and has appropriate range of motion upon resistance, (CN V-trigeminal). Client is able to raise eyebrows, smile, puff out cheeks and stick out tongue showing (CN VIIfacial) is intact.. This was tested by finger to nose. Client’s hearing is bilaterally even and he passed the whisper test (Cranial nerve VIII, Acoustic). Client can swallow without difficulty (CN IX glossopharyngeal) intact. Uvula rises with phonation (CN X-vagus), and the tongue is midline with protrusion (CNXII- hypoglossal). When observing the client’s gait and coordination, the client shows no abnormalities or difficulties, tested by heel to shin and Romberg test. Client can shrug shoulders and turn head against resistance (CN XI spinal accessory). Did not apply to much pressure to head due to migraine. Triceps, biceps, brachioradialis, patellar, Achilles, plantar all bilaterally are +2. Client’s bilaterally hand strength is bilaterally even. He can feel sharp and dull on all extremities.

Assessment/Plan After performing a neurological assessment all of the client’s cranial nerves are intact. Client shows no signs or stroke or pre-seziure symptoms. The plan for this client is to have orthostatic vitals performed to make sure that he does not have an increased risk of falls or dizziness when standing. As well as starting fluids to make sure he is properly hydrated and recording intake and output to make sure he is voiding. An actual risk for this client could be depression do to not being able to go outside due to the photosensitivity. A potential risk for this client would be a stroke if his migraine does not go away, with the increasing intracranial

4 pressure as well as increased blood pressure. Education I would give this patient is to lay in a dark room, with no television or lights and to rest. Instead of using a warm compress I would suggest a cold one to constrict the blood vessels in his head.

5 References Author’s Last Name, First initial. Middle initial. (Year). Title of article. Journal Title, Volume Number(Issue number), Page numbers....