neurological assessment
DESCRIPTION
teaching nursesTRANSCRIPT
How to assess neurological patients?
Dr. Surat Tanprawate, MD, FRCPTNorthern Neuroscience Center
Chiangmai University
Assessment
Assessment
An assessment is a consideration of someone or something
and a judgement about them
= evaluation
Why neurological patients need special
care?
The answer is ....
The answer is ....
• Emergency and life threatening conditions
The answer is ....
• Emergency and life threatening conditions
• Difficult to interpreted
The answer is ....
• Emergency and life threatening conditions
• Difficult to interpreted
• Various conditions
The answer is ....
• Emergency and life threatening conditions
• Difficult to interpreted
• Various conditions
• Complex diseases
For diagnosis
For diagnosis
For evaluated the prognosis
For diagnosis
For evaluated the prognosis
For evaluated the response to treatment
No routine
Routine
Step to approach
What is the patient’s condition(or diseases)
How we assess?
Protocol
• Specific disorder
•Goal
• Specific assessment
• Pitfall
Neurological disorder
• General neurological examination
• Acute stroke
• Seizure
• Coma and alteration of consciousness
• Neuromuscular respiratory failure
General neurological examination
• Consciousness
• Cranial nerve examination
• Motor system
• Sensory system
• Reflex
• Coordination
Specific neurological examination
• Depend on specific conditions or diseases
• e.g. COMA: Look “CPOMR”
• Stroke: Look “localizing neurological symptoms”
Acute stroke
Acute stroke
Acute stroke
Assessment goal
• before IV rtPA use
• progression
• complication from stroke
• complication from thrombolysis
• associated medical condition
• baseline evaluation for follow up
General evaluation and F/U: use score
• GCS
• general evaluation
• NIHSS
• specific for stroke evaluation
• Barthel index
• disabilities
GCS
•Don’t appropriated evaluation in stroke patient
Aphasia: problems to evaluate
• Prehospital stroke assessment
• Cincinnati Stroke Scale
• Los Angeles Prehospital Stroke Screen(LAPSS)
• ABCD Score
• Acute Assessment Scale
• Canadian Neurological scale
• European Stroke Scale
• Glasgow Coma Scale(GCS)
• NIH Stroke Scale(NIHSS)
• Scandinavian Stroke Scale
• Functional assessment
• Berg Balance Scale
• Lawton IADL Scale
• Modified Rankin Scale
• Stroke Impact Scale
• Outcome assessment
• Barthel Index
• American Heart Association Stroke Outcome Classification
• Glasgow Outcome Scale
NIHSS Estimation: The Procedure
Helps to categorize patients
Low NIHSS, thrombolysis less indicatedMid-range NIHSS, thrombolysis indicatedHigh NIHSS, thrombolysis less indicatedNIHSS 10-20 optimal for thrombolysis?
Quantification directs therapies
NIHSS 10-20 optimal for thrombolysis?
NIHSS: 11 items
Brain herniation
Early detection for brain herniation
•Eyelid apraxia
•Unqual pupil: pupillary constriction(Horner’s syndrome)
•Change of consciousness
Disorder of consciousness
Coma patients
Use CPOMR for evaluate the lesion
C: ConsciousP: PupilO: Ocular movementM: Motor responseR: Respiratory pattern
Glasgow Coma Scale
• 1974:
• Graham Teasdale and Bryan J. Jennett(Neurosurgery at University of Glasgow)
• Initially used to assess level of consciousness after head injury
Individual elements as well as the sum of the score are important.
Generally, comas are classified as: ▪ Severe, with GCS ≤ 8 ▪ Moderate, GCS 9 - 12
▪ Minor, GCS ≥ 13.
Confusing point
1. No motor response 2. Extension to pain 3. Abnormal flexion to pain 4. Flexion/Withdrawal to pain 5. Localizes to pain 6. Obeys commands
Control of muscle tone
Different location
Different posture
Decorticate posturing
Decorticate responseDecorticate rigidityflexor posturing"mummy baby"
Arms flexed, or bent inward on the chest, the hands are clenched into fists, and the
legs extended
Decorticate posturingdamage to the mesencephalic region
the corticospinal tract
Decerebrate posturing
Decerebrate responseDecerebrate rigidityExtensor posturing
the head is arched back, the arms are extended by the sides, and the legs are extended.
Decerebrate posturing indicates brain stem damage or rather
damage below the level of the red nucleus (eg. mid-collicular lesion)
Pupillary pathway
Seizure: pitfall
•Seizure VS convulsion
•Epileptic seizure VS non-epileptic seizure
•Status epilepticus
Seizure
• Temporary abnormal electro-physiologic phenomenon of the brain
• It can manifest as
• an alteration in mental state
• tonic or clonic movements
• psychic symptoms (such as déjà vu or jamais vu)
Convulsion
Non-convulsive seizure
Temporal lobe epilepsy
Frontal lobe epilepsy
Massage
•Seizure may be not convulsion
•Convulsion may be not seizure
Status epilepticus
• มีอาการชักอย่าง
• ต่อเนื่อง
• ยาวนาน
life-threatening condition in which the brain is in a state of persistent seizure
Definition
Defined as one continuous unremitting seizure lasting longer than 5-10 minutes
OR
Recurrent seizures without regaining consciousness between seizures for greater than 30 minutes.
Observe symptoms of seizure
Observe symptoms of seizure
• Pitfall
Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
• recognized signs of non-convulsive seizure
Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
• recognized signs of non-convulsive seizure
• prolong SE: brain damage: less motor sign
Observe symptoms of seizure
• Pitfall
• missing of non-convulsive seizure
• recognized signs of non-convulsive seizure
• prolong SE: brain damage: less motor sign
• Look silence area: eye, small motor groups(fingers)
Neuromuscular respiratory failure
• To detection signs of respiratory failure
• Pitfall
• Deoxygenation: late signs
• Paradoxical abdominal movement: early sign
• Change of Vital capacity: early detection
Thanks U for your attention
SURAT TANPRAWATE, MD, FRCPT
Blog: www.neurologycoffeecup.blogspot.com