Neurological Assessment Data Collection and Handover Report for Clinical Practice

This article discusses the process of collecting neurological assessment data and creating a handover report for clinical practice. It covers pain examination, neurological examination, and provides insights into anatomy and physiology. The article also includes a sample handover report using the SBAR format.

Running head: INTRODUCTION TO CLINICAL PRACTICE
Introduction to Clinical Practice
Name of the Student:
Name of the University:
Author Note:

1INTRODUCTION TO CLINICAL PRACTICE
Question 1:
Explain what neurological assessment data should be collected from the patient to
ensure any neurological deficit is identified? Linking your assessment reasoning to
anatomy and physiology, provide a rationale for collecting this data.
For the patient who has head injury must go through two major analysis namely, pain
examination and physical examination.
For pain examination, the patient should undergo through basic pain management
protocols consisting Provocative, Quality, Region, Severity and Time. For Provocative and
Palliative examination the patient need to answer that what activity or factor make the pain
better or worse. In Quality analysis, the patient will be asked to describe his or her paining
sensation. In Region and Radiation part, the patient will be asked to indicate the part of his or
her head where the main is intense and through where the pain is spreading (Appleton et al.,
2015). Patient has to also voice if any other part of the body is in pain. Next in Severity part,
the patient has to identify the intensity of the pain by selecting a number from 1 to 10, where
1 represents lowest intensity and 10 represents the highest intensity of the pain. In the last
part of the pain management, the patient has to say the duration of this pain or when the
patient has started to feel the pain.
In case of head injury, any possible neurological impact should be associated with
either brain or Cerebellum. The neurological examination should contain the detailed
documentation of sensory neuron and motor responses concerning the patient’s reflexes. Any
deeper investigation such as Neuroimaging will be not required initially (O’Brien, 2017).
However taking patient’s history is the most important task that has to be done in
neurological examination. It contains Age, gender, past medical history, drug history and
family and social history. The five most important components of any neurological

2INTRODUCTION TO CLINICAL PRACTICE
examination is mental status testing, Cranial Nerve test, Muscle strength, tone and bulk,
testing Reflexes, Testing motor function coordination and muscle movement, sensory
function and Gait. Understanding the patient’s neurological state at the time of questioning
is also important. Any linguistic abnormalities can indicate the effected Hemisphere. Most of
the cases left hemisphere is responsible for the language.
Glasgow Coma Scale (GCS) can be used for the assessment of consciousness.
Fundoscopy will help to estimate intracranial pressure, which can be very helpful if the
patient has a history of microvascular disease. Cranian Nerve Examination will help to test
the sense of smell, eye movement, sympathetic and parasympathetic pupil movement, hearing
strength, pharyngeal movement and reflex, tongue movement, and facial muscle movement
(Thaler, et al., 2015). Spinothalamics test can be done to demine the functionality of paint
spinal nerves. Finger to nose testing, alternating finger movement, hand movement can be
tested to test the coordination. Gait testing will help to determine the visual, vestibular,
cerebellar, motor and sensory status (Setänen et al., 2016). Walking and standing tests are
usually conducted as a major part of Gait testing.
Question 2 :
Document a written handover you will provide to the doctor who will take over the
patient’s care. Your report must use the SBAR format.
Situation: Hello, this is RN ‘RN name’. I am caring for Sam G. I am referring the patient to
you regarding her condition of lateral ankle sprain.
Background: Sam G. is a 16 years old girl, who has fallen from 6 feet height while
conducting an physical activity. She is suffering from moderate pain in lateral ligament
sustaining more than 3 hours. The pain is in the outside space of her left foot. She is not

3INTRODUCTION TO CLINICAL PRACTICE
currently in any kind of medication. She does not have any allergy in any specific group of
medicine.
Assessment: Sam ranked her pain as 5 out of 10, with a sharp and radiating pain. The pain
becomes worse while trying to move her feet in anticlockwise movement. Trying to put little
amount of pressure is causing comparatively sustainable pain. The region of pain is limited
to Talus, Fibula and Cuboid bone specific ligament area (Keene et al., 2016). She does not
has any previous history of ligament injuries in this specific area. Both Inversion and
Eversion movement of the foot are switching immediate sharp pain. The most suspected
cause of the injury is receiving sudden impact at Talipes Vrus position of foot.
Recommendation: I think Sam would have benefit from some pain medication of moderate
course. Some physiotherapy would be helpful to recover the ligament injury (Janssen et al.,
2016). As per my opinion, in this condition she needs to keep her left ankle and feet region at
rest for at least 5 days. Any additional examination or labs can be done as per your reference.

4INTRODUCTION TO CLINICAL PRACTICE
Reference:
Appleton, J., Ilinca, A., Lindgren, A., Puschmann, A., Habahbeh, M., Siddiqui, K., ... &
Hayton, T. (2015). The TOS2 Study: an International Multi-Centre Audit Assessing
the Standard of Neurological Examination (P4. 190). Neurology, 84(14 Supplement),
P4-190., doi: 10.1136/jnnp-2015-312379.1
Janssen, K. W., van der Zwaard, B. C., Finch, C. F., Van Mechelen, W., & Verhagen, E. A.
(2016). Interventions preventing ankle sprains; previous injury and high-risk sport
participation as predictors of compliance. Journal of science and medicine in
sport, 19(6), 465-469., doi: 10.1016/j.jsams.2015.06.005
Keene, D., Mistry, D., Nam, J., Tutton, E., Handley, R., Morgan, L., ... & Chesser, T. J.
(2016). The ankle injury management (AIM) trial: a pragmatic, multicentre,
equivalence randomised controlled trial and economic evaluation comparing close
contact casting with open surgical reduction and internal fixation in the treatment of
unstable ankle fractures in patients aged over 60 years, doi:
10.3310/hta20750
O’Brien, M. D. (2017). The Neurological Examination: Aeromedical Considerations. In The
Neurosciences and the Practice of Aviation Medicine (pp. 237-240). CRC Press.,
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Setänen, S., Lehtonen, L., Parkkola, R., Aho, K., Haataja, L., PIPARI Study Group, ... &
Eurola, A. (2016). Prediction of neuromotor outcome in infants born preterm at 11
years of age using volumetric neonatal magnetic resonance imaging and neurological

5INTRODUCTION TO CLINICAL PRACTICE
examinations. Developmental Medicine & Child Neurology, 58(7), 721-727., doi:
10.1111/dmcn.13030
Thaler, H. W., Schmidsfeld, J., Pusch, M., Pienaar, S., Wunderer, J., Pittermann, P., ... &
Mousavi, M. (2015). Evaluation of S100B in the diagnosis of suspected intracranial
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1202-1208., doi: 10.1089/neu.2017.5182