Acute Stroke Management Resource: Neurological Assessment 2007.

transcript

Acute Stroke Management Resource:Neurological Assessment

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

Cranial Nerves: Extraocular Movements Oculomotor (III), Trochlear (IV), Abducens (VI)

Cranial Nerves Facial Sensation: Trigeminal (V)

Cranial Nerves Facial Strength: Facial (VII)

Smile, show your teeth, lift your eyebrows

Cranial Nerves Palate and Tongue: Glossopharyngeal (IX),Vagus (X)

Ask patient to say “ah”

Motor Function Tone and Strength

Ask patient to close eyes, arms extended with palms upward

Neurological Assessment: Coordination and Gait

Heel-to-shin test

Finger-Nose-Finger test

Neurological Assessment: Reflexes

Plantar reflex exam

Deep tendon reflex exam

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

Acute Stroke Management Resource: Neurological Assessment 2007.

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