Advanced Neuro Assessment Keith Rischer, RN. Cranial Nerves.

Advanced Neuro Assessment

Keith Rischer, RN

Cranial Nerves

Cranial Nerves Made Simple

Stroke Recognition

~80% of ischemic strokes will have one or more of these symptoms

Neuro AssessmentLevel of Consciousness

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

Neuro AssessmentOrientation/Ability to Follow Commands

Neuro AssessmentGlasgow 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 AssessmentCognitive 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 AssessmentSpeech (Presence of Dysarthria)

Dysarthria is usually associated with facial droop or tongue weakness and indicates a risk for impaired swallowing

Neuro AssessmentCommunication/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 AssessmentPupils-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 AssessmentPupils

Neuro AssessmentExtraocular Movements (EOMs)-Abducens VII

To assess EOMs, ask the patient to To assess EOMs, ask the patient to follow your finger or a pen through the follow your finger or a pen through the 6 fields6 fields

Neuro AssessmentExtraocular Movements (EOMs)

Neuro AssessmentFacial 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

Neuro AssessmentTongue-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 AssessmentVisual 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.

Neuro AssessmentMotor Strength

Hand grasps, dorsi and plantar flexion are helpful but testing of the arms and legs is most useful in stroke patients.

Neuro AssessmentUpper 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.

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

Neuro AssessmentSensation 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 AssessmentCoordination/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 AssessmentCoordination/Balance-Cerebellum

Observe gait during ambulation. Ataxic and wide-based gaits are common in

patients with impaired coordination or balance.

QUESTIONS??