acute stroke management resource: neurological assessment 2007
TRANSCRIPT
Acute Stroke Management Resource:Neurological Assessment
2007
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
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
Localization
HemisphereAnterior circulationPosterior circulationCerebellum
Brain Stem Spinal Cord Peripheral Neuropathy Muscle
History
HistoryTime of symptom onset
o Accurate time of symptom onset is criticalo Obtain from patient or person present when the
patient was last seen normal
Associated featureso Seizure, loss of consciousness
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
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
Neurological Assessment
Level of consciousness Screening for aphasia Cranial Nerve assessment Motor function Coordination and gait Reflexes Sensory function
Level of Consciousness
Most ischemic stroke patients are conscious
Assessment of level of consciousnessAsk the patient:
o What month is it?o How old are you?
Response to commands:o Ask patient to open and close their fisto Ask patient to open and close their eyes
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
Cranial Nerves Funduscopic Examination: Optic (II)
Identify disk, sharpness of margins
Examine macular area for anterior lesions
Follow vessels emerging from diskwww.heartandstroke.ca/
profed
Cranial Nerves Visual Fields: Optic (II)
www.heartandstroke.ca/profed
Cranial Nerves Pupillary Response: Optic (ll) and Oculomotor (lll) Assess size prior to light Elevation of eyelid
www.heartandstroke.ca/profed
Cranial Nerves: Extraocular Movements Oculomotor (III), Trochlear (IV), Abducens (VI)
www.heartandstroke.ca/profed
Cranial Nerves Facial Sensation: Trigeminal (V)
www.heartandstroke.ca/profed
Cranial Nerves Facial Strength: Facial (VII)
Smile, show your teeth, lift your eyebrows
www.heartandstroke.ca/profed
Cranial Nerves Palate and Tongue: Glossopharyngeal (IX),Vagus (X)
Ask patient to say “ah”
www.heartandstroke.ca/profed
Motor Function Tone and Strength
Ask patient to close eyes, arms extended with palms upward
www.heartandstroke.ca/profed
Neurological Assessment: Coordination and Gait
Heel-to-shin test
Finger-Nose-Finger test
www.heartandstroke.ca/profed
Neurological Assessment: Reflexes
Plantar reflex exam
Deep tendon reflex exam
www.heartandstroke.ca/profed
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
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
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
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
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
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
