Assessment: The Neurologic
important aspect of the neurologic assessment is the history of the present
illness. The initial interview provides an excellent opportunity to
systematically explore the patient’s current con-dition and related events
while simultaneously observing overall appearance, mental status, posture,
movement and affect. De-pending on the patient’s condition, the nurse may need
to rely on yes-or-no answers to questions, on a review of the medical record,
or input from the family or a combination of these.
disease may be stable or progressive, with both in-termittent symptom-free
periods as well as times with fluctua-tions in symptoms. The health history
therefore includes details about the onset, character, severity, location,
duration, and fre-quency of symptoms and signs; associated complaints;
precipi-tating, aggravating, and relieving factors; progression, remission, and
exacerbation; and the presence or absence of similar symp-toms among family
members. The nurse may also use the inter-view to inquire about any family
history of genetic diseases.
Included in the health history is a review of the
medical history, including a system-by-system evaluation. The nurse should be
aware of any history of trauma or falls that may have involved the head or
spinal cord. Questions regarding the use of alcohol, med-ications, and
recreational drugs are also included. The history-taking portion of the
neurologic examination is critical and, in many cases of neurologic disease,
leads to an accurate diagnosis.