Scribd
Upload
3K views

Retdem Script Neuro

The document describes a student nurse conducting a full assessment of a patient. The nurse introduces herself to the patient and obtains identifying information. She explains that she will assess the patient's musculoskeletal, neurological, and lymphatic systems. The assessment includes inspection, palpation, and range of motion tests. The nurse proceeds to evaluate the patient's mental status, orientation, memory, attention span, and level of consciousness using standardized tests. The patient demonstrates normal findings on all aspects of the assessment.

Uploaded by

Kristinelou Marie N. Reyna
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
3K views

Retdem Script Neuro

The document describes a student nurse conducting a full assessment of a patient. The nurse introduces herself to the patient and obtains identifying information. She explains that she will assess the patient's musculoskeletal, neurological, and lymphatic systems. The assessment includes inspection, palpation, and range of motion tests. The nurse proceeds to evaluate the patient's mental status, orientation, memory, attention span, and level of consciousness using standardized tests. The patient demonstrates normal findings on all aspects of the assessment.

Uploaded by

Kristinelou Marie N. Reyna
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

LAST RETDEM SCRIPT

*knock* Good morning Ma’am. Can I come in? My name is Kristinelou Marie N. Reyna, a student
nurse from Southwestern University PHINMA. I am here from 8 am-4pm to assist you in all of your
needs.

I don’t see an armband with your name on it. Can you please state your full name and DOB? So how
would you like me to address you?

Okay so Ms. ______ I am going to assess your musculoskeletal, neurologic as well as your
peripheral lymphatic system in order for me to check and observe your muscles and bones as well as
your joints and identify areas that are deviated from normal findings to prevent further complication.
This will involve some palpation, inspection and measuring, will you be okay and comfortable with me
having physical contact with your limbs

So this procedure should take around 20-30 mins. Does that sound ok to you?

Great!

Now I’ll assist you first Ms. _____ to change into your patient gown so that you are comfortable and in
order for me to have easy access in the assessment areas.

I will begin first the assessment by doing a general survey on the physical appearance and hygiene of
the patient.

(Normal): Upon inspection, the patient is alert and conscious. The patient appears her stated
age. The sexual development is appropriate for her gender and age as well. The patient’s
clothes are fit, in good condition and appropriate to weather and temperature. The patient is
clean and well-groomed. No signs stains on hands and dirty nails. The skin color is fair and
uniform without obvious lesions. The patient’s body is proportional and symmetrical. Posture
is erect and comfortable for her age which is a normal finding.

So now I’ll proceed in assessing the Neurovascular system of the patient by assessing her mental
status. So I’ll be evaluating the mental status of the patient with LOMA. (Language, Orientation,
Memory and Attention Span)

Okay so Ms. Rose, can you explain to me your understanding about a proverb, “The early bird
catches the worm?”

(Ask a question and then instruct pt. to write her answer/s)

(Normal): Upon inspection, the speech is clear, moderately paced, and culturally appropriate.
The volume is just within normal range as well. The pt. was able to express freely herself
through verbal and nonverbal cues such as writing which is a normal finding.

Next I will proceed in assessing the patient’s orientation to person, place and time.

So Ms. Rose can you tell me your name again? Your mother’s name? How about your father’s
name? Do you have any idea where are you right now? Can you tell me the time and date today?

(Normal): Upon inspection, patient is alert and oriented to what is happening at the time of the
interview and physical assessment. The patient responds to my questions and interacts
appropriately.

Next I will proceed in assessing the patient’s memory and this will be in 3 phases, the immediate
recall, recent and remote memory.

IMMEDIATE RECALL
Ok so Ms. Rose kindly listen to what I will say. 7-4-3. And can you repeat the numbers I just said.

Okay kindly listen again. 7-4-3-5. Repeat the numbers. Okay good.
7-4-3-5-7. Kindly repeat the numbers but this time in a backward manner.

RECENT
Okay so Ms. Rose how did you get to the clinic? What did you eat during your breakfast?

REMOTE
Okay so Ms. Rose can you tell me or describe what happened to your birthday 5 years ago?

(Normal): Upon inspection, the patient was able to recall her memory from a long time ago up
until the recent, w/o any difficulties which is a normal finding.

Okay so now I’ll proceed in assessing the Attention span of the pt.

So Ms. Rose can you recite the alphabet for me?

(Normal): Upon inspection, the patient is attentive and cooperative with the assessment.

Now I will proceed in evaluating the level of consciousness of the patient with the use of Glasgow
coma scale. This tests three major areas: Eye, motor and verbal response. (pt. should be supine)

(Normal): So upon inspection, the patient is alert, oriented, spontaneous, converses and
responses to verbal command with a total of 15 points which is a normal finding.

The highest score is 15 and the lowest is 3. So this also tests the extent of brain injury of the
patient. For minor, it is graded from 13-15, for moderate its 9-12 and for severe brain injury,
the Glasgow coma grade is from 3-8.

You might also like