Presentation on theme: "Advanced Neuro Assessment Keith Rischer, RN. Cranial Nerves."— Presentation transcript:
Advanced Neuro Assessment Keith Rischer, RN
Cranial Nerves Made Simple
Stroke Recognition ~80% of ischemic strokes will have one or more of these symptoms
Neuro Assessment Level of Consciousness Level of Consciousness is most likely to be impaired in patients with hemorrhagic or large ischemic strokes
Neuro Assessment Orientation/Ability to Follow Commands
Neuro Assessment Glasgow Coma Scale The Glasgow Coma Scale score only needs to be assessed if the patient has an altered level of consciousness (LOC) Remember that the GCS is only intended to measure eye opening, verbal response and motor response as it relates to LOC. It does not replace assessment of motor strength, speech, or eye function.
Neuro Assessment Cognitive Ability Altered cognitive ability is very common following stroke and is associated with an increased risk for falls Poor judgment, impaired recent memory and impulsiveness are most common
Neuro Assessment Speech (Presence of Dysarthria) Dysarthria is usually associated with facial droop or tongue weakness and indicates a risk for impaired swallowing
Neuro Assessment Communication/Language (Aphasia) Common abnormalities include word finding difficulty, hesitant or stuttering speech and use of wrong or made-up words. Aphasia is often mistaken for confusion!
Neuro Assessment Pupils-Oculomotor III Pupils should be assessed in any stroke patient with an altered level of consciousness or who is at risk for increased ICP Hemorrhagic Strokes ( ICH and SAH) Large ischemic stroke, in particular strokes resulting from middle cerebral artery (MCA) occlusion or in the cerebellum
Neuro Assessment Pupils
Neuro Assessment Extraocular Movements (EOMs)-Abducens VII To assess EOMs, ask the patient to follow your finger or a pen through the 6 fields
Neuro Assessment Extraocular Movements (EOMs)
Neuro Assessment Facial Motor and Sensory-Trigeminal V Th ere are 3 bra nch es of the trig emi nal ner ve so tes t sen sati on in all 3 are as of the fac e. Us e the Is the sa me or diff ere nt? tes tin g me tho d. There are 2 branches of the facial nerve so ask the patient to smile to test the lower face and close eyes tightly against resistance and/or wrinkle forehead for upper face
Neuro Assessment Tongue-Hypoglossal XII It is important to test to tongue function to identify patients at risk for impaired swallowing Testing: Ask the patient to stick out tongue and move side to side The tongue will deviate toward the weak side
Neuro Assessment Visual Field Cut-Optic II Visual Field Testing: Have patient look at the examiners nose Examiner holds out his/her arms at approximately 45°, 1½ - 2 feet from the patient Examiner varies moving fingers on the right, left or both hands and the patient identifies which are being moved Patients with expressive aphasia may need to point to indicate where movement is seen.
Neuro Assessment Motor Strength Hand grasps, dorsi and plantar flexion are helpful but testing of the arms and legs is most useful in stroke patients.
Neuro Assessment Upper Motor Strength Check upper and lower extremities for strength against gravity/resistance, compare one side to the other Hand grasps bilaterally Push hands against yours Have pull arms towards themselves Upper extremities: Ask patient to raise arms and hold up for approximately 10 seconds If unable to lift arms off bed, raise arms for the patient then release and observe ability to keep raised If able to overcome gravity, provide resistance by pressing down on extremities and assess the patients strength against your own.
Neuro Assessment Lower Motor Strength Lower extremities: Ask patient to raise legs, one at a time and hold each up for approximately 5 seconds If unable to raise leg off bed, raise leg for patient, then release and observe ability to keep it raised Test strength against resistance as with the upper extremities Plantar flexion/dorsiflexion Pronator drift (tests for mild weakness) Have the patient hold out arms with palms up and eyes closed Watch for downward drift of the arm for several seconds The patients eyes must be closed because s/he will correct the drift if it is seen
Neuro Assessment Sensation of the arms and legs Gross Sensory Assessment: Does it feel the same or different? Ask the patient to report any perceived numbness, tingling, etc. To perform a general sensory exam: Brush your finger or an object against the upper arms and upper legs and ask if the patient is able to feel it. Test one side, then the other. If the patient is able to feel both sides, test both simultaneously and ask if the two sides feel the same or different
Neuro Assessment Coordination/Balance-Cerebellum Testing – Have patient: hold arms out to sides then alternate touching nose with right and left index fingers alternate between own nose and examiners finger, test one arm, then the other move heel down the shin from knee to ankle Limb ataxia cannot be tested in patients with significant weakness
Neuro Assessment Coordination/Balance-Cerebellum Observe gait during ambulation. Ataxic and wide-based gaits are common in patients with impaired coordination or balance.