Abbreviated Assessment

1. Abbreviated Assessment Slides 1-22

2. Neuro Assessment

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. 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

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

19. 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)

20. 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

21. 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

22. 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

23. Complete Neuro Assessment Slides

24. Neuro Assessment

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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)

33. 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

34. 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

35. 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

36. 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

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

38. 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

39. 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

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

41. 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)

42. 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

43. 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

44. 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

45. 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

46. 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)

47. 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

48. 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

49. 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

50. 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