Neuro Assessment

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Neuro Assessment

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Neuro Assessment

• When assessing the patient, always compare
  left to right
  Asymmetry is abnormal
  Do your exam the same
  
  way every time start at
  the top and work down
  Assess LOC and Language,
  Cranial Nerves Motor
  Cerebellar Sensory

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Neuro Assessment

• Obtain Complete past history
  including any events that may
  have left a residual deficit Complete list of
  meds, including OTCs, vitamins,
  supplements and recreational drugs
  Information must be from a
  reliable source

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Neuro Assessment

• Components of consciousness
  Arousal eye opening
  Awareness aware of self
  the environment with the ability to
  focus and interact

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Neuro Assessment

• Levels of Consciousness Fully
  Conscious awake, alert oriented x4
  Confused disoriented to time, place, person
  or situation short attention span poor memory
  easily bewildered Lethargic oriented
  with slow, sluggish speech mental processes
  responds appropriately Obtunded arouses to
  stimulation responds with 1-2 words follows 1
  step commands to stimulation
  

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Neuro Assessment

• Stuporous lies quietly with minimal
  movement responds only to vigorous and repeated
  stimulation opens eyes and responds to pain
  appropriately makes incomprehensible sounds
  
  Comatose sleep-like state with eyes closed
  does not respond appropriately to bodily or
  environmental stimuli no verbal sounds

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Neuro Assessment

• Language Speech assessed together located in
  the dominant hemisphere (left in most, including
  lefties)
  LEFT written spoken language, reasoning,
  number skills, scientific knowledge, right
  hand control RIGHT insight, 3-D forms, art
  awareness, imagination, music
  awareness , left hand control

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Neuro Assessment

• Note speech patterns, fluency, word
  usage ability to follow 1 or 2 step
  commands (must cross the midline)
  ability to name common objects and their
  use

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Neuro Assessment

• Aphasia a disorder in processing language
  apraxia of speech disorder in programming of
  speech (dominant hemisphere) dysarthria
  disorder in mechanics of speech (cranial nerve
  weakness)

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Neuro Assessment

• Brocas Aphasia (motor, expressive) unable to
  convert thoughts to words speech limited to
  yes/no, name or 5 words or less difficulty in
  finding correct word difficulty repeating words
  writing understands profanity and ability to
  carry a tune well preserved
  Wernickes Aphasia (sensory,
  receptive) fluent speech lacks
  content meaning does not
  understand spoken or written word
  substitutes other words or uses non-words
  perseverates not aware of speaking errors
  

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Neuro Assessment

• Example A patient with Brocas might say
  where is book? and a patient with Wernickes
  might say where is the paper of the cover?
  Global Aphasia
  both motor and receptive non-fluent speech with
  poor comprehension and repetitive ability
  
  Dysarthria loss of articulation, phonation d/t
  muscle weakness or loss of breath control
  

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Neuro Assessment

• Cranial Nerves
  CN I Olfactory smell skip except
  in facial trauma CN II Optic
  vision count fingers or movement in
  all quadrants and periphery in each eye
  
  blink to threat in temporal and nasal
  quadrants if unable to
  participate

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Neuro Assessment

• Cranial Nerves CN III Oculomotor moves
  eyes in all directions except
  outward and down in opens
  eyelid constricts pupil
  CN IV Trochlear moves eyes down
  and in

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Neuro Assessment

• Cranial Nerves CN VI Abducens moves
  eyes outward
  EOMs assessment of eye movement in
  all directions ( III, IV VI)

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Neuro Assessment

• Cranial Nerves CN V Trigeminal 3
  branches sensation to the
  face, cornea and scalp opens
  jaw against resistance CN
  VII Facial moves
  the face taste

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Neuro Assessment

• Cranial Nerves CN VIII Acoustic
  2 branches, acoustic (hearing)
  and vestibular (balance)
  CN IX
  Glossopharyngeal
  moves the pharynx (swallow,
  speech gag) CN X Vagus
  voice quality

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Neuro Assessment

• Cranial Nerves CN XI Spinal Accessory
  turns head and elevates
  shoulders
  CN XII Hypoglossal
  moves tongue

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Neuro Assessment

• Cranial Nerves Test gag, swallow
  and speech together ( IX,
  X, XII) CN
  Tips observe for nystagmus with EOMS (2-3 beats
  normal with lateral gaze)
  diplopia (double vision) cover one eye, should
  clear if sixth nerve palsy (offer eye patch over
  good eye)

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Neuro Assessment

• Motor Exam use the motor grading scale to
  maintain objectivity and eliminate confusion
  5/5 strong against resistance 4/5
  weak against resistance 3/5
  overcomes gravity offers no
  resistance 2/5 cannot
  overcome gravity moves with
  gravity eliminated 1/5 contracts
  muscle to stimulus 0/5 no muscle
  movement
  Assess hand grips for
  equality

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Neuro Assessment

• Drift Assessment test for motor weakness
  Arm hold arms out with palms up eyes closed
  pronator drift hands pronate (roll over)
  subtle weakness (NIHSS doesnt test for this)
  motor drift arm drifts downward
  cerebellar drift arm drifts back
  toward head or out
  to side
  Leg
  no need to close eyes motor leg
  drifts toward bed

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Neuro Assessment

• Movements are purposeful or non-purposeful
  purposeful picking at tubings or bed linens,
  scratching nose localizing moving toward or
  removing a painful stimulus must cross the
  midline occurs in the cortex withdrawal
  pulling away from pain occurs in the
  hypothalamus
  non-purposeful do not
  cross the midline abnormal flexion
  (decorticate) rigidly flexed arms
  and wrists fisted hands occurs in
  upper brainstem abnormal extension
  (decerebrate) rigidly, rotated inward
  extended arms
  with flexed wrists and fisted
  hands occurs in midbrain or pons

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Neuro Assessment

• Eliciting movements using central
  pain Trapezius pinch deep pressure to
  trapezius muscle Supraorbital
  pressure pressure under supraorbital
  ridge Sternal pressure knuckle
  pressure to sternum do not rub!
  Peripheral Pain nailbed pressure
  may elicit a spinal cord reflex which
  can be reproduced in a brain
  dead patient

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Neuro Assessment

• Apraxias Partial or complete inability to
  execute purposeful movements (even with strength
  or ability) Ideational inability to remember a
  command Ideomotor inability to
  formulate a plan to accomplish
  a task (scratch nose, brush teeth, draw a
  clock, comb hair)
  Speech motor speech
  programming errors
  word substitutions common Dressing
  neglect of one side of body in grooming
  dressing (especially right hemisphere and
  parietal injuries) may put both arms in 1
  sleeve or use toothbrush to comb hair)

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Neuro Assessment

• Cerebellar Testing assess coordination, smooth
  movement (synergy) and position sense weakness
  occurs on the side of the deficit
  Observe for leaning to one side
  Test finger to
  nose, making sure pt has to fully extend arm
  (eyes open) Ataxia wavering or
  jerking of finger as it nears
  target heel bouncing along or
  falling off shin Dysmetria past
  pointing target Nystagmus jerky,
  rather than smooth, eye movements

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Neuro Assessment

• Sensory Best assessed with the cooperative
  patient but can be assessed by using pain
  observe for symmetry of grimace or withdrawal
  with pain. Eyes closed Use
  cheekbone, forearm lower leg
  Patient identifies which area and
  which or both sides note amount
  of grimace/withdrawal if using pain
  Test enough times to ascertain validity
  of responses

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Neuro Assessment

• Unconscious Exam assessment of brainstem and
  motor movement in response to pain
  observe breathing pattern, position in bed
  and movement of extremities prior to
  stimulating patient note
  hemodynamics prior to
  starting exam use the
  least amount of stimulus
  first voice or loud clap, shake then
  pain assess as many of the
  CNs as possible

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Unconscious Neuro Assessment

• Cranial Nerves some cranial nerves will not be
  testable assess pupil size
  reaction stimulate eyelashes note
  any slight blink open eyelids and
  observe position of eyes and whether eyes
  are stationary or roving
  assess for blink to threat
  from center and all sides
  test corneal reflex by lightly touching
  cornea with
  wisp of cotton
  observe for
  facial symmetry
  assess gag by
  touching each side of pharynx
  noting movement, gag or
  grimace

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Unconscious Neuro Assessment

• Motor movement/muscle tone
  Movement observe for purposeful or
  non-purposeful movement, spontaneously or in
  response to pain. Note posturing.
  
  Tone lift arm 12-15 inches off bed and dropa
  rapid drop signifies coma and a slow drops
  signifies consciousness. Assess legs by flexing
  knees while keeping heels on bed. Release knees
  the leg will externally
  rotate and
  drop rapidly. A normal leg
  slowly extends to bed.

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Neuro Assessment

• Abnormal Reflexes Babinski initial
  inflection of great toe in response stroking of
  sole upgoing toe is abnormal Grasp
  involuntary grasp in response to stimulation of
  palm abnormal in an adult Dolls eyes
  impairment of eye movement to opposite side when
  head is turned damage to brainstem no
  movement loss of
  brainstem

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Neuro Assessment

• Neuro Hemodynamics indicative of brainstem
  damage BP varies initially higher to perfuse
  brain during early herniation, alternately high
  or low late herniation is low and dependent on
  position Heart rhythm/ rate
  tachy/brady syndrome to increase
  perfusion bradycardia in late
  herniation Respiratory patterns
  CheyneStokes bilat hemisphere
  Central Neurogenic Hyperventilation
  midbrain, upper pons
  Apneustic lower pons Ataxic
  medulla

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Brain Teaser

• Brain Teaser

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QUESTIONS

• DONT SHOUT OUT Please raise your
  hand

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Question 1

• Whats the earliest and most reliable indicator
  of increased intracranial pressure?

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Question 2

• Which cranial nerves control eye movements?

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Question 3

• A patient whose has dysarthria and coughs when
  he attempts to drink has weakness in which 3
  cranial nerves?

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PLEASE

• return all penlights to me.
  THANKS!