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Acute Stroke Management Resource: Neurological Assessment 2007
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Neurological Assessment: Objectives To present the rationale for a focused neurological assessment To present the components of a two minute neurological assessment To present the components of a focused neurological assessment To review three assessment scales used in stroke
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Focused Neurological Assessment History Stroke onset, risk factors and symptoms General Medical Assessment Associated conditions, etiology, additional investigations Neurological Examination Localizes the lesion, exclusion of other symptoms Rules out stroke mimics Suggests provisional diagnosis Determines additional investigations Determines management care plan
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Localization Hemisphere Anterior circulation Posterior circulation Cerebellum Brain Stem Spinal Cord Peripheral Neuropathy Muscle
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History History Time of symptom onset o Accurate time of symptom onset is critical o Obtain from patient or person present when the patient was last seen normal Associated features o Seizure, loss of consciousness
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General Medical Assessment ABC: airway, breathing, circulation Blood Pressure tPA candidates: <185/110mmHg Non tPA candidates: 220/120mmHg Pulse: irregularity may indicate atrial fibrillation Temperature: >37.5°C is an independent predictor of poor outcome Blood glucose: hyperglycemia associated with worse stroke outcomes General system screen
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2 Minute Neurological Examination Assess: Pupils, fundi, visual fields, extraocular movements Ask patient to: Show me your teeth, say “ah” and stick out your tongue Assess: Facial sensation Muscle tone and strength Sensory function Reflexes Coordination
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Neurological Assessment Level of consciousness Screening for aphasia Cranial Nerve assessment Motor function Coordination and gait Reflexes Sensory function
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Level of Consciousness Most ischemic stroke patients are conscious Assessment of level of consciousness Ask the patient: o What month is it? o How old are you? Response to commands: o Ask patient to open and close their fist o Ask patient to open and close their eyes
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Screening for Aphasia Aphasia: loss of ability to use written and oral language 25% of stroke survivors 50% of individuals with left hemisphere strokes Bedside screening includes: Comprehension Expression & naming Repetition Reading Dysarthria
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Cranial Nerves Funduscopic Examination: Optic (II) Identify disk, sharpness of margins Examine macular area for anterior lesions Follow vessels emerging from disk www.heartandstroke.ca/profed
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Cranial Nerves Visual Fields: Optic (II) www.heartandstroke.ca/profed
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Cranial Nerves Pupillary Response: Optic (ll) and Oculomotor (lll) Assess size prior to light Elevation of eyelid www.heartandstroke.ca/profed
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Cranial Nerves: Extraocular Movements Oculomotor (III), Trochlear (IV), Abducens (VI) www.heartandstroke.ca/profed
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Cranial Nerves Facial Sensation: Trigeminal (V) www.heartandstroke.ca/profed
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Cranial Nerves Facial Strength: Facial (VII) Smile, show your teeth, lift your eyebrows www.heartandstroke.ca/profed
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Cranial Nerves Palate and Tongue: Glossopharyngeal (IX),Vagus (X) Ask patient to say “ah” www.heartandstroke.ca/profed
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Motor Function Tone and Strength Ask patient to close eyes, arms extended with palms upward www.heartandstroke.ca/profed
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Neurological Assessment: Coordination and Gait Heel-to-shin testFinger-Nose-Finger test www.heartandstroke.ca/profed
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Neurological Assessment: Reflexes Plantar reflex exam Deep tendon reflex exam www.heartandstroke.ca/profed
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Stroke Scales: National Institute of Health Stroke Scale Measures 11 items Physiological deficits Does not measure activity, ADL or participation abilities Scoring Quantitative, weighted to severity 0-42, higher score indicative of greater neurological deficits Characteristics Reflects comprehensive neurological exam Results correlate with presenting symptoms Primarily suited to acute care Accurate, reliable and well validated Training required to ensure accuracy in use
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Stroke Scales: Canadian Neurological Scale Measures 6 items Impairment or physiological deficit Scoring 0-11.5, lower score indicative of greater neurological deficit Characteristics Reflects common areas related to stroke presentation Primarily used in acute care Used in conjunction with Glasgow Coma Scale Accurate, reliable, sensitive to change, predictive of death, reinfarction and functional independence at 6 months Training resources available from HSFO
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Stroke Scales: Glasgow Coma Scale (GCS) Measures 3 items Level of consciousness or coma Scoring 3-15 with lower score indicative of greater neurological deficit Characteristics Developed as a standardized and valid tool for assessing level of consciousness Not felt to be sensitive enough for stroke patients who do not have impaired level of consciousness Used in conjunction with CNS if level of consciousness is impaired
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Conclusions Rapid assessment and triage key to optimal treatment CT scan required to exclude hemorrhage Knowledge of typical stroke symptoms key Anatomical and etiological diagnosis necessary Exclusion of stroke mimics vital
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Resources American Association of Neuroscience Nurses www.aann.org American Stroke Association www.strokeassociation.org Brain Attack Coalition www.stroke-site.org Canadian Hypertension Education Program www.hypertension.ca/chep/en/default.asp Canadian Stroke Strategy www.canadianstrokestrategy.ca European Stroke Initiative www.eusi-stroke.com
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Resources Heart and Stroke Foundation Prof Ed www.heartandstroke.ca/profed Heart and Stroke Foundation of Canada www.heartandstroke.ca Internet Stroke Centre www.strokecenter.org National Institute of Neurological Disorders and Stroke www.ninds.nih.gov National Stroke Association www.stroke.org/site/PageServer?pagename=HOME Scottish Intercollegiate Guidelines Network www.sign.ac.uk StrokeEngine www.medicine.mcgill.ca/strokengine
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