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Advanced Neuro Assessment
Keith Rischer, RN
Cranial Nerves
Cranial Nerves Made Simple
Stroke Recognition
~80% of ischemic strokes will have one or more of these symptoms
Neuro AssessmentLevel of Consciousness
Level of Consciousness is most likely to be impaired in patients with hemorrhagic or large ischemic strokes
Neuro AssessmentOrientation/Ability to Follow Commands
Neuro AssessmentGlasgow Coma Scale
The Glasgow Coma Scale score only needs to be assessed if the patient has an altered level of consciousness (LOC)
Remember that the GCS is only intended to measure eye opening, verbal response and motor response as it relates to LOC. It does not replace assessment of motor strength, speech, or eye function.
Neuro AssessmentCognitive Ability
Altered cognitive ability is very common following stroke and is associated with an increased risk for falls
Poor judgment, impaired recent memory and impulsiveness are most common
Neuro AssessmentSpeech (Presence of Dysarthria)
Dysarthria is usually associated with facial droop or tongue weakness and indicates a risk for impaired swallowing
Neuro AssessmentCommunication/Language (Aphasia)
Common abnormalities include word finding difficulty, hesitant or stuttering speech and use of wrong or made-up words.
Aphasia is often mistaken for confusion!
Neuro AssessmentPupils-Oculomotor III
Pupils should be assessed in any stroke patient with an altered level of consciousness or who is at risk for increased ICP Hemorrhagic Strokes (ICH and SAH) Large ischemic stroke, in particular strokes resulting from
middle cerebral artery (MCA) occlusion or in the cerebellum
Neuro AssessmentPupils
Neuro AssessmentExtraocular Movements (EOMs)-Abducens VII
To assess EOMs, ask the patient to To assess EOMs, ask the patient to follow your finger or a pen through the follow your finger or a pen through the 6 fields6 fields
Neuro AssessmentExtraocular Movements (EOMs)
Neuro AssessmentFacial Motor and Sensory-Trigeminal V
There are 2 branches of the facial nerve so ask the patient to smile to test the lower face and close eyes tightly against resistance and/or wrinkle forehead for upper face
Neuro AssessmentTongue-Hypoglossal XII
It is important to test to tongue function to identify patients at risk for impaired swallowing
Testing: Ask the patient to stick out tongue and move side to side The tongue will deviate toward the weak side
Neuro AssessmentVisual Field Cut-Optic II
Visual Field Testing: Have patient look at the examiner’s nose Examiner holds out his/her arms at approximately 45°, 1½
- 2 feet from the patient Examiner varies moving fingers on the right, left or both
hands and the patient identifies which are being moved Patients with expressive aphasia may need to point to
indicate where movement is seen.
Neuro AssessmentMotor Strength
Hand grasps, dorsi and plantar flexion are helpful but testing of the arms and legs is most useful in stroke patients.
Neuro AssessmentUpper Motor Strength
Check upper and lower extremities for strength against gravity/resistance, compare one side to the other
Hand grasps bilaterally Push hands against yours Have pull arms towards themselves
Upper extremities: Ask patient to raise arms and hold up for approximately
10 seconds If unable to lift arms off bed, raise arms for the patient
then release and observe ability to keep raised If able to overcome gravity, provide resistance by
pressing down on extremities and assess the patient’s strength against your own.
Neuro Assessment Lower Motor Strength
Lower extremities: Ask patient to raise legs, one at a time and hold each up for
approximately 5 seconds If unable to raise leg off bed, raise leg for patient, then release and
observe ability to keep it raised Test strength against resistance as with the upper extremities Plantar flexion/dorsiflexion
Pronator drift (tests for mild weakness) Have the patient hold out arms with palms up and eyes closed Watch for downward drift of the arm for several seconds The patient’s eyes must be closed because s/he will correct the drift if
it is seen
Neuro AssessmentSensation of the arms and legs
Gross Sensory Assessment: “Does it feel the same or different?” Ask the patient to report any perceived numbness,
tingling, etc. To perform a general sensory exam:
Brush your finger or an object against the upper arms and upper legs and ask if the patient is able to feel it. Test one side, then the other.
If the patient is able to feel both sides, test both simultaneously and ask if the two sides feel the same or different
Neuro AssessmentCoordination/Balance-Cerebellum
Testing – Have patient: hold arms out to sides then alternate touching nose with
right and left index fingers alternate between own nose and examiners finger, test one
arm, then the other move heel down the shin from knee to ankle
Limb ataxia cannot be tested in patients with significant weakness
Neuro AssessmentCoordination/Balance-Cerebellum
Observe gait during ambulation. Ataxic and wide-based gaits are common in
patients with impaired coordination or balance.
QUESTIONS??