1. Advanced Neuro Assessment
Keith Rischer, RN

2. Cranial Nerves

3. Cranial Nerves Made Simple

4. Stroke Recognition
The Cincinnati prehospital stroke scale is, by far, the most widely used stroke screening tool for EMS crews in the United States. Nearly 80% of all strokes will manifest at least one of these 3 symptoms and a high level of sophistication with neurological assessment is not required to perform it.
In areas of the hospital that do not regularly care for neuro patients, we encourage nursing staff to use this tool to assess for possible stroke. If symptoms exist, the RRT is called and they perform additional screening and notify the stroke neurologist.
~80% of ischemic strokes will have one or more of these symptoms 4

5. Neuro Assessment Level of Consciousness
Level of Consciousness is most likely to be impaired in patients with hemorrhagic or large ischemic strokes

6. Neuro Assessment Orientation/Ability to Follow Commands

7. 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.

8. 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

9. Neuro Assessment Speech (Presence of Dysarthria)
Dysarthria is usually associated with facial droop or tongue weakness and indicates a risk for impaired swallowing

10. 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!

11. 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

12. Neuro Assessment Pupils

13. Neuro Assessment Extraocular Movements (EOMs)-Abducens VII
To assess EOMs, ask the patient to follow your finger or a pen through the 6 fields

14. Neuro Assessment Extraocular Movements (EOMs)

15. Neuro Assessment Facial Motor and Sensory-Trigeminal V
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
There are 3 branches of the trigeminal nerve so test sensation in all 3 areas of the face.
Use the “Is the same or different?” testing method.

16. 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

17. Neuro Assessment Visual Field Cut-Optic II
Visual Field Testing:
Have patient look at the examiner’s 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.

18. 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.

19. 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 patient’s strength against your own.

20. 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 patient’s eyes must be closed because s/he will correct the drift if it is seen

21. 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

22. 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

23. Neuro Assessment Coordination/Balance-Cerebellum
Observe gait during ambulation.
Ataxic and wide-based gaits are common in patients with impaired coordination or balance.

24. QUESTIONS??