FNA-Pengkajian Sistem Saraf

Summary

The video script presents a comprehensive assessment of a patient's nervous system by Nurse Sarah. The examination covers a wide range of neurological tests, including the assessment of sensory functions, reflexes, muscle strength, coordination, and balance. Nurse Sarah carefully checks the patient's sensory responses, vision, hearing, and motor skills through various tests such as the GCS, smell identification, eye movement, and the evaluation of muscle strength and tone. Throughout the process, the patient demonstrates normal responses, concluding with the delivery of the results and a reminder of the next steps in the medical care plan.

Takeaways

• 😀 The nurse begins the assessment by introducing themselves and verifying the patient's identity using a bracelet.
• 😀 The patient is asked about their condition, including complaints such as headaches, dizziness, or weakness in limbs.
• 😀 A detailed neurological examination is performed, starting with a check of the patient's sense of smell using different scents like coffee and eucalyptus oil.
• 😀 The nurse checks the patient's vision by testing their ability to read letters and numbers from a distance, verifying if their glasses are still appropriate.
• 😀 The nurse assesses the patient's field of vision and eye movements, ensuring symmetry and no involuntary movements.
• 😀 Sensory functions, including sharp and dull sensations on the face, are tested with the patient having their eyes closed.
• 😀 The patient’s reflexes, such as the blink reflex and muscle function in the face, are tested for normal responses.
• 😀 The nurse conducts a taste test, offering different flavors (salty, sweet, bitter) to check the patient’s ability to differentiate tastes.
• 😀 A series of tests are performed to assess motor functions, including checking muscle strength, coordination, and the ability to resist pressure with both hands and legs.
• 😀 The patient’s balance and coordination are assessed through simple tasks like standing with eyes closed, walking, and performing hand movements, all showing normal results.

Q & A

What is the first step in the nursing assessment of the nervous system?

The first step is identifying the patient by checking their bracelet and confirming their full name and date of birth.

What tools and materials are needed for the neurological examination?

The tools include a penlight, tuning fork, pen, ground coffee, eucalyptus oil, sugar, salt, cotton, paper clip, magazine, reflex hammer, tongue spatula, yellow plastic, tissue, hand sanitizer, and clean gloves if needed.

What is the Glasgow Coma Scale (GCS) and how is it used in the assessment?

The Glasgow Coma Scale (GCS) assesses the patient's consciousness level. It includes eye opening, verbal response, and motor response. The nurse evaluates these aspects when first meeting the patient, assigning scores based on the patient's responses.

How does the nurse assess the patient's sense of smell?

The nurse asks the patient to close their eyes, cover one side of the nose, and identify different smells such as coffee, eucalyptus oil, and soap.

What visual checks are performed during the assessment?

The nurse checks the patient's visual acuity, field of vision, eye movements, eyelid function, pupil reflex, and symmetry of the eyelids and pupils.

What does the nurse check for when examining the patient's facial muscles?

The nurse checks the temporal and masseter muscles by asking the patient to bite and check for symmetrical contractions on both sides of the face.

How does the nurse assess the patient's ability to differentiate between different sensations?

The nurse uses different stimuli such as sharp or blunt objects and asks the patient to identify them while their eyes are closed.

What is the purpose of the balance test and how is it conducted?

The balance test is conducted to evaluate the patient's ability to maintain balance. The patient is asked to stand with their eyes closed for 30 to 60 seconds while the nurse ensures they do not fall.

What is assessed during the muscle strength tests?

The nurse assesses the strength and contraction of various muscle groups, including the shoulders, neck, face, arms, and legs. The patient is asked to resist the nurse’s pressure to check for symmetrical strength.

How does the nurse assess the patient's coordination?

The nurse asks the patient to follow movements, such as touching their nose and then the nurse's finger with their right hand, and performing rapid opening and closing of the hands to assess coordination.