10/11/2019 40th Annual Neurorehabilitation Conference on Traumatic Brain Injury, Stroke and Other Neurological Disorders Saturday & Sunday, November 16 & 17, 2019 Hyatt Regency Cambridge 575 Memorial Drive Cambridge, MA encompasshealth.com/braintreerehab Neuro Assessment For Nurses Vincent M. Vacca, Jr., MSN, RN 1 Disclosures • None 2 Case Study • The case study is fictional and used only for instructional purposes • References are cited throughout and at the end of the presentation • Nothing presented will be off label 3 1 10/11/2019 Objectives • At the conclusion of this presentation the participant will be able to: 1. Discuss 3 assessments of normal neurological function. 2. Describe 3 assessments of abnormal neurologic function using validated stroke measurement scale. 3. List 3 evidence based nursing care interventions for individuals with neurologic abnormalities from stroke. 4 What are we “Normally” doing at this moment? • Maintaining posture • Looking • Listening • Thinking • Processing information – Visual/Auditory/Emotional • Learning • Creating memories • Feeling thirsty/hungry • Planning dinner • Other………….. 5 ? Are you able to……. • See and eat food from the left side of your plate? • Dress the left side of your body? • Understand why people cheer at sporting event? • Or why people experience pain from an injury? • Recall these numbers (5438693) in 2 minutes? • Recognize the face of someone you previously met? 6 2 10/11/2019 Frontal Lobe Functions • Hypothalamus and limbic systems send large number of projections to the frontal lobes. • Mediate biological drives (thirst, hunger) and emotions (fear, anger) • Frontal lobe networks fuse biological drives and impulses with knowledge to satisfy them. – Fusion = goal-oriented behavior. • Frontal lobes project to motor systems enabling motivational states to initiate overt behavior. 7 Frontal Lobe Intact - Injury/Damage • Intact frontal lobes – Resist biological drives to satisfy long-term goals • Injured/damaged frontal lobes – Regulation of drives is dysfunctional/lost – Poor Planning, – Lack of Insight, – Impulsivity, – Loss of Flexibility, – Poor Social Judgment. 8 Knowledge: The convergence of language, perception, and memory • Now imagine the impact of a brain injury on your studies, profession, goals, life. • What it would be like for family members to live with you? • What were those numbers? 5 4 3 8 6 9 3 9 3 10/11/2019 10 Human Brain • Consists of 100 billion neurons & around 100,000 miles of blood vessels. • There are more than 100,000 chemical reactions happening in the human brain every second. • In each minute of ischemia, 1.9 million neurons, 14 billion synapses, and 12 km (7.5 miles) of myelinated fibers are destroyed. Stroke. 2006; Proc Natl Acad Sci U S A. 2012 11 12 4 10/11/2019 Despite increase in global burden of stroke • advances are being made. • Stroke is the fifth leading cause of death if considered separately from other cardiovascular diseases. • In the United States (US), an estimated 795,000 strokes occur annually, and the prevalence of stroke increases with age. • The lifetime risk of all strokes is higher in women; attributed to longer life-expectancy. • An estimated 6.8 million (2.8%) of people in the US are living after a stroke, including 3.8 million women and 3 million men. 13 Stroke in women • The lifetime risk of stroke and mortality due to stroke is higher in women than men. • Some factors that contribute to an increased risk of stroke in women include: – pregnancy, – oral contraceptive use (especially when combined with smoking), – preeclampsia/eclampsia, – gestational diabetes, – migraine with aura, – increased risk of atrial fibrillation, – hormonal replacement therapy. 14 Nearly half of stroke survivors in the US • have residual deficits, including weakness or cognitive dysfunction, 6 months after stroke, which translates into ≈200 000 more disabled women than men. • Globally, at least 5 million people die from strokes and millions other remain disabled. • Stroke is the leading cause of adult disability worldwide. 15 5 10/11/2019 RFI….. • Fewer than half of 9-1-1 calls for stroke events were made within 1 hour of symptom onset, and fewer than half of those callers thought stroke was the cause of their symptoms. (~795K strokes/yr) Stroke. published online February 6, 2014 • The brain is exquisitely sensitive to ischemia and other physiologic imbalances; & once injured, the adult brain heals very poorly. (Emerg Med Clin N Am 30 (2012). • And when it doesn’t = – neurological dysfunction, – abnormalities, – deficits 16 BE-FAST#’s (balance, eyes, face, arm, speech, time/911) • One or more of face weakness, arm weakness, and speech difficulty symptoms are present in 88% of all strokes and TIAs. Stroke. published online February 6, 2014 17 General examination is important • Trauma • Seizures • Carotid bruits • Congestive heart failure. • Cardiac murmurs, arrhythmias • Pneumonia/pulmonary infiltrates • Evidence of coagulopathies, platelet disorders 18 6 10/11/2019 The goal of neuro-critical care for the patient • is to optimize long-term functional outcomes and quality of life by minimizing the amount of brain tissue that is lost. • optimize brain perfusion, limit secondary brain injury, and compensate for dysfunction in other organ systems. • Given data indicating that acute stroke patients might spend an average of 5 hours in the emergency department (ED), it is clear that optimal neurocritical care should begin in the ED and not be delayed until the patient arrives in the intensive care unit (ICU). (Emerg Med Clin N Am 30 (2012) 19 Recommended Not Recommended • Manage ABC’s • Excessive IV fluids • Cardiac Monitoring • Dextrose-containing fluids • O2 Sats > 94% in non-hypoglycemic • Establish IV access patients • • Determine blood glucose Medications by mouth and treat accordingly (maintain NPO until passes dysphagia screen) • Perform Dysphagia Screen Stroke 2013 before anything by mouth • Determine time of symptom onset or last known normal, and obtain family contact information, preferably a cell phone 20 • The use of a stroke rating scale, preferably the NIHSS is recommended (Class I; Level of Evidence B). Stroke 2013 • NIHSS <5 most strongly associated with D/C home • NIHSS 6-13 most strongly associated with D/C to rehab • NIHSS >13 most strongly associated with D/C to nursing facility Schlegel, et al. 2003 Stroke 2011 Modified NIHSS: 1abc, 4, 5, 9. 21 7 10/11/2019 NIHSS: stroke-specific quantitative (0-42) scale assesses: – level of consciousness, (Brainstem, either/both hemisphere) – language function, (Left hemisphere) – neglect, (Right hemisphere) – visual field, (Either hemisphere, occipital lobe) – eye movements, (Brainstem, both hemispheres) – facial palsy, (Either hemisphere) – motor strength, (Either hemisphere, basal ganglia, brainstem) – sensory function, (Thalamus, basal ganglia) – coordination (Cerebellum) • Although most patients with potentially disabling symptoms will have NIHSS scores ≥4, certain patients, such as those with gait disturbance, isolated aphasia, or isolated hemianopia, may have potentially disabling symptoms although their NIHSS score is just 2. Ther Clin Risk Manag. 2012; 8: 87–93 22 NIHSS Scores/Severity 23 Neuro Assessment especially for Suspected Stroke Patients • Levels of consciousness Assessment & descriptors : – Alert – Drowsy – Stuporous – requires repeated stimulation, but will speak briefly and could be accurate – Obtunded – requires repeated noxious stimulation for one word or grunt response – Comatose – reflex response/movements only AANN Core Curriculum 6th edition 8 10/11/2019 Neuro Assessment especially for Suspected Stroke Patients • Level of consciousness questions: – Name – Date – Place – Hospital (Which one) – Situation – Why are you here? – City – State – Season • Typically we expect all to be correct; but the fewer correct the more concerned we are. • Compare w/ baseline. • Can possibly R/O or R/I signs of delirium Neuro Assessment especially for Suspected Stroke Patients • Visual Acuity: • Test 4 quadrants (RUQ/RLQ/LUQ/LLQ) – For awake alert cooperative patients – test peripheral vision by: “tell me when you see my fingers wiggling” OR “how many fingers do you see”? – Keep them looking at your nose & bring the fingers for each quadrant in slowly. – This tests CNs II,III,IV,VI,VIII • Corneal reflex or do they blink to threat? – From all 4 quadrants? • This tests CN II, CN V, CN VII corneal/blink reflex 6 Cardinal Fields of Gaze – Cranial Nerves III, IV, & VI 9 10/11/2019 Neuro Assessment for (Anyone) but especially for Suspected Stroke Patients • If there's a problem with speech, ask the patient to repeat: • 'pa pa pa‘ • 'la la la‘ • 'ta ta ta‘ • 'ka ka ka‘ • You could combine all this into one and have them say Pawtucket 3 times listening for ability to make the sounds clearly Emerg Med Clin N Am 27 (2009) 1–16 Goldstein & Greer • This will reveal if the problem is with the – lip movements (CN VII), (Pa/Paw) – tongue movements (CN XII) (Ta/Tu ) – pharyngeal (CN’s IX or X) (Ka/Cut ). Neuro Assessment especially for Suspected Stroke Patients • Level of consciousness commands: – Open eyes – Close eyes – Make fist – Relax fist • These maneuvers test: comprehension; CN III (Oculomotor) eyelid muscles & VII (Facial) & motor pathways to extremities • Shrug shoulders/turn head side to side evaluates CN XI (spinal accessory) Upper Motor Neuron disorder (Stroke) the nerve is dysfunctional in the cortex; however the forehead has DUAL innveration - the forehead will be spared with