Focused Assessment of the Neurologic System
Develop a plan of care for the neurologic system
Explain how to conduct a physical assessment of the neurologic system
Demonstrate documentation of the neurologic system assessment findings
In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client. You can access the grading rubric for this assignment here: Writing Rubric.Preview the document
Review the case scenario.
Lydia Ocampo is a 69-year-old female who is brought in to the clinic today by her husband, Dr. Danillo Ocampo. She has had a mild decline in her mental status over the past several years, but recently things have progressed. Her husband is concerned that she might have Alzheimer’s disease. She was hospitalized two weeks ago with pneumonia and a urinary tract infection and was on intravenous antibiotics.
Onset: You ask Mrs. Ocampo to explain what brings her here today. She tells you she is not really sure. She tells you her husband wanted her to come because she has been forgetting things. She tells you that she does forget things sometimes, but that is because she is “getting old.” You ask Dr. Ocampo to tell you when he noticed things were getting worse with her cognitive status. He tells you that since she was discharged from the hospital, he has noticed that Lydia doesn’t want to go out with their friends or go for walks, and she seems confused more often.
Duration: You ask Dr. Ocampo how long her periods of confusion are. He tells you that she used to start talking about their son (who died at age 22) like he was still living. He would remind her that Emillo was killed in a car accident, and she would remember he had died. Now she continues to talk about Emillo as if he were alive and gets angry when he tries to tell her that Emilio died. She also gets frustrated more easily when she can’t remember how to turn the TV on or start the dishwasher.
Characteristics: You ask Dr. Ocampo to describe Lydia’s current day and her ability to carry out her daily activities. He tells you that Lydia used to be able to take a shower and get dressed in the morning. She would go for walks with him during the day and out to dinner with friends. She would read, watch TV, and work in her garden in the backyard. She had periods of forgetfulness and confusion but could be redirected. Now, he cannot trust her to be outside by herself; she wandered out of the backyard and into a neighbor’s house last week. She wakes up at night, gets confused, and doesn’t remember where she is. When he tries to reorient her, she becomes angry. She has also stopped reading and working in the garden and has more difficulty getting dressed in the morning by herself.
Aggravating or alleviating factors: Redirecting or reorienting Lydia used to help, but now that seems to frustrate her more. Distractions in the environment and strange places also make her dementia worse.
Other background information: Lydia Ocampo was born and raised in the Philippines and came to this country when she was 18. She has no living relatives in the United States and has a niece and nephew in the Philippines. Dr. Ocampo is a retired pathologist and has class II heart failure and hypertension. He is Lydia’s primary care giver and was very distressed when she was recently hospitalized.
Neurological exam: You decide to perform the Mini Cog Test. She scores 0 on the word recall, and her clock drawing is incomplete. Her mood during the exam is irritable, and she argues with her husband as he responds to questions. Her reflexes and motor strength are normal and her gait is normal. Her swallowing reflex is normal.
Diagnosis and treatment: You suspect her dementia is worsening and that she is in the early stages of Alzheimer’s disease. She undergoes brain imaging studies and neuropsychological testing, and a diagnosis of Alzheimer’s is made.
Provide answers for the items below.
You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items:
Write a detailed explanation describing what you would say to the student when explaining the assessment conducted and the findings. Discuss any additional assessments you would also perform such as the mini-mental exam. What are other potential factors related to the probable diagnosis you would be concerned about with this client?
Explain how you would document your findings in the medical record.
Develop your plan of care. Identify one to two nursing diagnoses and one to two nursing interventions related to those diagnoses. These interventions should include evidence based practices from the Hartford Institute for Geriatric Nursing. Cite the references used in your plan in correct format.
Identify what client education should be done for Lydia and her husband, given her background and presenting concerns. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.
Explain how you would determine care giver strain on Dr. Ocampo.
Save and submit your assignment.
When you have completed your assignment, save a copy for yourself in an easily accessible place and submit a copy to your instructor using the dropbox.
Giddens, J. F. (2010). The neighborhood: faculty navigation guide. Upper Saddle River, NJ: Pearson Education, Inc.
PubMed Health (2011, September 26) Alzheimer’s disease. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001767
Fletcher, K. (2012, August). Dementia. Retrieved from http://consultgerirn.org/topics/dementia/want_to_know_more
Mayo Clinic Staff (2013, January 19). Alzheimer’s disease. Retrieved from http://www.mayoclinic.com/health/alzheime
RUBRIC RN to BSN-3.docxPreview the document
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