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Abbreviated Assessment. Slides 1-22. Neuro Assessment. Neuro Assessment.

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neuro assessment1
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

neuro assessment2
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

neuro assessment3
Neuro Assessment

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

neuro assessment4
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

neuro assessment5
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

neuro assessment6
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

neuro assessment7
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
neuro assessment8
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)

neuro assessment9
Neuro Assessment

Broca’s 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 preservedWernicke’s 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

neuro assessment10
Neuro Assessment

Example: A patient with Broca’s might say “where is book”? and a patient with Wernicke’s 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

neuro assessment11
Neuro Assessment

Cranial Nerves: CN I Olfactory: smell; skip except in facial trauma CNII 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

neuro assessment12
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

neuro assessment13
Neuro Assessment

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

neuro assessment14
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

neuro assessment15
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

neuro assessment16
Neuro Assessment

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

neuro assessment17
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)

neuro assessment18
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

neuro assessment19
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 doesn’t 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

neuro assessment20
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

neuro assessment22
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

neuro assessment23
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

neuro assessment24
Neuro Assessment

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

neuro assessment25
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

neuro assessment26
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

neuro assessment27
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

neuro assessment28
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
neuro assessment29
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)

neuro assessment30
Neuro Assessment

Broca’s 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 preservedWernicke’s 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

neuro assessment31
Neuro Assessment

Example: A patient with Broca’s might say “where is book”? and a patient with Wernicke’s 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

neuro assessment32
Neuro Assessment

Cranial Nerves: CN I Olfactory: smell; skip except in facial trauma CNII 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

neuro assessment33
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

neuro assessment34
Neuro Assessment

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

neuro assessment35
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

neuro assessment36
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

neuro assessment37
Neuro Assessment

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

neuro assessment38
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)

neuro assessment39
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

neuro assessment40
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 doesn’t 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

neuro assessment41
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

neuro assessment42
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

neuro assessment43
Neuro Assessment

Apraxias: Partial or complete inability to execute purposeful movements (even withstrength 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)

neuro assessment44
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

neuro assessment45
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

neuro assessment46
Neuro Assessment

Unconscious Exam: assessment of brainstem and motor movement in response to pain * observe breathing pattern, position in bed andmovement 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

unconscious neuro assessment
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

unconscious neuro assessment1
Unconscious Neuro Assessment

Motor movement/muscle toneMovement: observe for purposeful or non-purposeful movement, spontaneously or in response to pain. Note posturing. Tone: lift arm 12-15 inches off bed and drop…a 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.

neuro assessment47
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 Doll’s eyes: impairment of eye movement to opposite side when head is turned = damage to brainstem; no movement = loss of brainstem

neuro assessment48
Neuro Assessment

Neuro Hemodynamics:indicative of brainstem damageBP: 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:Cheyne–Stokes: bilat hemisphere Central Neurogenic Hyperventilation: midbrain, upper pons Apneustic: lower pons Ataxic: medulla

brain teaser
Brain Teaser

Brain Teaser

questions
QUESTIONS

DON”T SHOUT OUT Please raise your hand

question 1
Question 1

What’s the earliest and most reliable indicator of increased intracranial pressure?

question 2
Question 2

Which cranial nerves control eye movements?

question 3
Question 3

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

please
PLEASE

return all penlights to me. THANKS!