NURSING CARE RELATED TO THE SENSORY AND
NEUROLOGICAL SYSTEMS
2-14
2-14. SENSORY FUNCTION
a. Sensory function is evaluated by testing perception of pain, touch, and position.
(1) Pain--using a safety pin, touch the skin as lightly as possible to elicit a sharp sensation.
(2) Touch--ask the patient to close his eyes. Use a piece of cotton or gauze to gently brush the skin on the patient's arms, legs, and feet. Ask the patient to tell you when and where he feels a touch.
(3) Position--ask the patient to close his eyes. Grasp one of the patient's digits (thumb, great toe) and move it up or down. Ask the patient to tell you which direction the digit is pointing. Do not exert any pressure with your grasp that will indicate which direction you are moving the digit.
b. Pupillary response is another sensory function indicator. Evaluate:
(1) Size in millimeters (do not use subjective terms such as dilated or pinpoint.)
(2) Equality in size of the pupils.
(3) Response to light.
