Divers Alert Network America. 6 West Colony Place Durham, NC 27705

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2 Acknowledgment DAN Education would like to thank those individuals who, through their tireless efforts and dedication, have made the development of these training programs a reality. Their actions make a difference in dive safety. Author: Patty Seery, MHS, DMT Contributors and Editors: Patty Seery, MHS, DMT, Frances Smith, MS, EMT-P, DMT, Brian H. Wake, DAN Director of Education Layout: Brian H. Wake, DAN Director of Education Divers Alert Network America 6 West Colony Place Durham, NC DAN America Education extension 555 DAN Emergency Services General Information Membership Information ext 333 DAN Education Fax All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise without prior written permission of Divers Alert Network, 6 West Colony Place, Durham, NC Neurological Assessment DAN

3 Table of Contents Standards and Procedures... 4 Overview... 4 Standards Summary... 5 Curriculum Subject Areas and Objectives... 6 Provider Skills and Objectives... 7 F-A-S-T... 8 Take a History... 9 Vital Signs Mental Function Cranial Nerves Motor Function Coordination and Balance Provider Assessment Question Key Answer Key DAN Neurological Assessment Provider Course Quick Reference Chart DAN Neurological Assessment 3

4 DAN Neurological Assessment Provider Course Standards and Procedures This Instructor Guide is for use of DAN Instructors who are authorized by DAN to conduct the DAN Neurological Assessment provider course. It is to be used in conjunction with the General Standards and Procedures section found in the DAN Instructor Manual. This course is intended for anyone who might come in contact with individuals exhibiting neurological symptoms regardless of possible causes. It is written to meet guidelines of the U.S. Occupational Safety and Health Administration (OSHA) and the Guidelines for Resuscitation as released by the International Liaison Council on Resuscitation (ILCOR)/American Heart Association (AHA) in October Overview The DAN Neurological Assessment course is designed as lay provider training where participants learn to perform a basic neurological examination as part of the initial first aid care. Scenarios included in each skill are suggestions only and may be altered to more closely reflect the environment in the location where the course is being conducted. The time needed to teach the course varies and depends on many factors, including the number of students and their ability to process the educational components of the program. Instructors who want to include subjects or training beyond the course requirements may do so only before or following the course. Any additional training must not be required for completion of course requirements. 4 Neurological Assessment DAN

5 STANDARDS SUMMARY Course Prerequisites: None Age: No minimum age requirement. Student-to-Instructor Ratio: 12:1 during skills development sessions Recommended course hours: Three (3) hours Knowledge development (lecture) hours = 1 Skills development (practice) hours = 2 Required student materials: DAN Neurological Assessment Provider Student Handbook DAN Neurological Assessment Provider Slate Required instructor materials: DAN Instructor Manual Reference copy of student handbook Reference copy of the DAN Neurological Assessment Provider Slate Required audiovisual materials: DAN Neurological Assessment video and instructor slides or DAN Neurological Assessment Online Knowledge Development Required equipment and supplies: DAN Neurological Assessment Provider Slate Pencil or other non-permanent/no smear writing implement Final Evaluation: Minimum score of 80% or above on the final written assessment. The instructor must review any missed questions on the examination or any information that is unclear with each participant to ensure 100 percent understanding of the material. Retraining Required: 24 months DAN Neurological Assessment 5

6 Neurological Assessment Curriculum Subject Areas and Objectives Students participating in this course will be able to answer the following questions at the end of the knowledge development section. Nervous System Overview o What are the primary components of the nervous system? o What is the functional unit of the nervous system? o What are possible causes of interruptions along neural pathways? Stroke o What are the two kinds of stroke? o How do strokes manifest? o What is the leading cause of long term disability? o How does prompt medical intervention affect injury and disability from a stroke? o What are the signs and symptoms of stroke? o What does the mnemonic FAST mean? Decompression Illness o What two conditions are included in decompression illness? o What are the most common signs and symptoms of DCI? Conducting a Neurological Assessment o When should an Emergency Assistance Plan be activated if you suspect a neurological injury? o What are the basic areas of a Neurological Assessment? o What functions are evaluated in the Mental Function part of the neurological assessment? o What functions are evaluated in the Cranial Nerves section of the neurological assessment? o How do motor function deficits manifest? o What are three sensory symptoms of DCI? o How are balance and coordination evaluated? 6 Neurological Assessment DAN

7 Neurological Assessment Provider Skills and Objectives Students who have participated in the skill development portion of this course will be able to: o F-A-S-T o Conduct a F-A-S-T assessment on a simulated patient suspected of having a neurological impairment o History o Interview a patient in a simulated scenario utilizing the S-A-M-P-L-E mnemonic to identify previous medical history and determine where he might have acute problems or feel discomfort. o Record findings in a usable format. o Vital Signs o Demonstrate proper technique for taking a pulse and determining respiration rate o Mental Function o Determine an individual s level of consciousness in a scenario with a simulated injury o Utilizing interview techniques, assess an individual s speech and language abilities orientation to person, place, date and time and event short term memory o Assess an individual s ability to do calculations utilizing a standardized protocol o Cranial Nerves o Assess control of eyes and facial muscles utilizing simple commands o Assess an individual s ability to hear o Motor Strength o Assess strength of muscle groups utilizing muscle isolation and resistance o Coordination and Balance o Assess and individual s coordination with a finger-nose-finger exercise o Determine presence of functional balance utilizing a straight walk and a Romberg test DAN Neurological Assessment 7

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9 Skill: F-A-S-T Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objective: Conduct a F-A-S-T assessment on a simulated patient suspected of having a neurol ogical impairment Rationale: Rapid intervention for neurological illnesses increases the chance of recovery. By doing the F-A-S-T assessment first, EMS can be activated and on the way while additional information is being gathered. Skill Description: Have victim remain seated during assessment. F - Have the patient smile and observe their face for asymmetry. Is one side drooping? Is the smile equal on both sides? A - Ask the patient to extend and raise both arms straight out in front. Can the patient raise both arms? If so, do both arms remain up or does one drift down? S - Ask the patient to repeat a simple phrase. Are all the words clear? Is there any slurring? Is the speech garbled? T - If any abnormal signs are present, call 911 immediately. Time is of the essence. Scenario: An older neighbor has dropped by to thank you for helping them earlier in the week with a yard project. Suddenly they look confused and scared. When you ask if something is wrong, they just look at you but do not respond. Instructor: What should you suspect and what action should you take? Students: Possibly a stroke. Conduct a F-A-S-T assessment. Call EMS. F-A-S-T Key Points 1. Time is critical so the F-A-S-T exam is a rapid assessment that confirms the need to activate EMS. 2. Use the mnemonic F-A-S-T to go through the assessment steps. DAN Neurological Assessment 9

10 Skill: Taking a History Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objective: 1. Interview a patient in a simulated scenario utilizing the S-A-M-P-L-E mnemonic to identify previous medical history and determine where he might have acute problems or feel discomfort. 2. Record findings in a usable format. Rationale: An important step to performing an on-site neurological assessment is to determine as clearly as possible any conditions that may have been present before the incident or injury. Without this information, signs and symptoms may be inappropriately associated with the current event. Weakness in one arm or leg, for example, may actually be related to a previous injury. Skill Description: Interview a simulated injured individual to identify any pre-existing conditions that may influence any neurological findings. Utilize S-A-M-P-L-E to conduct the interview. Signs/symptoms Allergies Medications Pertinent medical history Last oral intake Events leading up to the current situation Record findings on the neurological assessment slate Scenario: You neighbor is finally speaking and answering questions but does not feel well. The F- A-S-T exam showed some slight deficits but did not show any clear problem. You have called EMS but will have a short wait before they get there. Instructor: What can you do while you are waiting? Students: Interview your neighbor utilizing S-A-M -P-L-E Teaching Tip: If using an assistant, discuss with them in advance how this skill demonstration will be conducted and develop the scenario details. 10 Neurological Assessment DAN

11 History Key Points 1. Utilize S-A-M-P-L-E to conduct the interview to avoid missing key elements. 2. Ask open ended questions to avoid leading the patient to give answers that may not reflect his actual condition 3. Record your findings where indicated on the neurological assessment slate so they can be referred to later, possibly by health care providers DAN Neurological Assessment 11

12 Skill: Vital Signs Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objective: Demonstrate proper technique for taking a pulse and determining respiration rate Rationale: Determining basic vital signs are the first step in a neurological assessment. Vital signs should be monitored periodically until EMS arrives. Skill Description: To take a pulse Ask permission to touch the individual so you may take their pulse. Locate the groove on the inside of the wrist between the bone and tendon at the base of the thumb Place the fingertips of one hand into the groove. (Do not use your thumb) Use light pressure to feel the heartbeat via the pulse. Count for 30 seconds then multiply by 2 for beats per minute (heart rate) To determine respiration rate Continue to hold the wrist as if you were still doing heart rate so the injured person will not alter their breathing pattern Observe chest rise and fall or abdominal movement with breathing and count for 30 seconds then multiply by 2 for breaths per minute. Record your findings on the neurological assessment slate. Scenario: You have used S-A-M-P-L-E to guide questions to your neighbor. You have not yet checked their pulse and respirations. Instructor: What is the next step? Students: Take pulse and respirations. Teaching Tip: For pulse, sometimes it helps to have the injured person bend their wrist slightly. It is difficult to get a pulse on some individuals so if students are unable to find a pulse, have them practice on other students. Encourage them to practice on family and friends at home. For respiration, hold the wrist against the stomach as an aid in detecting breathing action. 12 Neurological Assessment DAN

13 Determining actual pulse and respiration is not critical. Recognizing whether an individual is in distress is critical so interventions can be utilized if necessary. Sometimes it is useful to take vital signs before getting their history. Order for these two skills is not critical. Vital Signs Key Points 1. For pulse, use fingertips. The thumb will provide false information as it has a strong pulse itself. 2. For respirations, avoid staring at the victim s chest (especially with females) 3. Count both for 30 seconds then multiply by two. DAN Neurological Assessment 13

14 Skill: Mental Function Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objectives: 1. Determine an individual s level of consciousness in a scenario with a simulated injury. 2. Utilizing interview techniques, assess an individual s a. speech and language abilities b. orientation to person, place, date and time and event c. short term memory 3. Assess an individual s ability to do calculations utilizing a standardized protocol. Rationale: Fortunately, most injured victim s exhibit normal mental function. However, even if the victim appears normal, do not omit these questions, as they may reveal confusion that is an indication of a serious problem. Skill Description: During the history portion you should have noticed the responsiveness of the individual. On the slate, indicate level of Consciousness: A Alert V Responds to verbal stimuli P Responds to painful stimuli U Unresponsive Speech and Language Ask them to follow a command like close your eyes and stick out your tongue. Ask them to repeat a simple phrase like no ifs, ands, or buts Point out three easily identified objects and ask them to name them IE Pencil, glass, coat Orientation Ask them to state their name, what day/date it is, what time it is approximately and if they know what happened. Short term memory Ask them to name the three objects identified earlier Abstract reasoning Ask them to explain how two things are related Eg.) Cat and Mouse; Father and Son; School and Classroom Calculations Ask them to count backwards from 100 by 7s. 14 Neurological Assessment DAN

15 Note any inability to complete a task on your slate Scenario: While waiting on EMS, your neighbor continues to seem confused about some things. Instructor: What else can you do while waiting on EMS? Students: Complete mental function assessment. Mental Function Key Points 1. Level of consciousness can be completed at any point where you are interacting with the injured person. 2. Objects selected for identification and recall should be simple everyday kinds of items. 3. Calculations do not have to be exact. Can they follow a steady pattern or are they skipping around or forgetting what they are doing? 4. Remember to note findings on your slate as your complete each task rather than depend on your own memory. 5. Treat the injured person gently and with empathy if they have difficulty with any portion of the assessment. DAN Neurological Assessment 15

16 Skill: Cranial Nerves Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objectives: 1. Assess control of eyes and facial muscles utilizing simple commands 2. Assess an individual s ability to hear Rationale: Neurological injuries can manifest in a number of ways. Some are very subtle and must be evaluated. Injuries affecting the cranial nerves are serious and must be treated immediately. Skill Description: Eye Control o Hold your finger about 3 feet (1 meter) in front of the injured person s face. Instruct them to hold their head still and follow your finger by only moving their eyes. o Move your finger up and down as well as left and right at a moderate pace. o Note any direction the eyes do not track or track together. Facial Control o Ask the injured person to close their eyes and smile. Movement and facial creases should be equal on both sides. (This step is a repeat of the F in the F-A-S-T assessment.) o Note asymmetry Hearing o Hold your hand about 1 foot (.3 meters) away from the injured person s ears o Snap or rub your fingers together at each ear individually. Have the person identify with which ear they are hearing and if the sound is equal on both sides. o This test may be difficult or impractical in a noisy environment like a moving boat. Scenario: Your neighbor is calm but still a little confused. Instructor: What is the next step? Students: Assess cranial nerves. 16 Neurological Assessment DAN

17 Cranial Nerves Key Points: 1. Keep motions at a moderate pace when checking eye control 2. Standing behind the person when checking hearing eliminates cues they may pick up on regarding what and where they should hear something. 3. Note any drooping or lack of equality form one side to the next on the slate. DAN Neurological Assessment 17

18 Skill: Motor Function Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objective: 1. Assess strength of muscle groups utilizing muscle isolation and resistance Rationale: Neurological injuries affecting the spinal cord can manifest itself as weakness or paralysis in the extremities. Skill Description: Each group of muscles must be isolated and assessed independently. Use your hand to provide resistance both pushing and pulling for most muscle groups. Notations should be made to reflect the strength of each side (left and right).note whether muscle strength as normal, weak, or paralysis. Make notations as you finish each muscled group rather than wait until all groups have been evaluated. Remember to ask permission to touch the person. Shoulders Have the injured person bring their arms up to shoulder level with their hands not quite together on from of their chest. Hands should not touch. Instruct the individual to push up against your hands as you push down on their elbows then as you push up from underneath their elbows. Biceps and triceps Have the injured person curl their arms up so their hands are in front of them. One arm at a time, support the elbow with one hand then both push and pull against their hand with your other hand. Instruct the individual to resist your pressure as you push then pull. Finger spread Have the injured person spread their fingers apart. Ask them to keep their fingers apart as you try to squeeze them together gently. Squeeze two fingers at a time (IE first finger and middle finger, middle finger and ring finger, ring finger and little finger) Both hands can be done simultaneously. 18 Neurological Assessment DAN

19 Hip flexors Have the injured person lift one leg so their foot is off the ground. Place your hand above the knee of the raised leg. Ask the individual to press up against the hand on the knee as you apply gentle downward pressure. Repeat for the other side Hamstrings and Quadriceps Place one of your hands underneath the knee of one leg to support the foot off the ground. Use the other hand to provide resistance to the calf just above the ankle. Have the individual press against your hand at the ankle while you provide resistance. Do each leg with resistance from both the front of the leg and behind the leg just above the ankle. Foot Support the calf off the ground with one hand. Place your other hand under the individual s foot. Ask them to press down against your hand. Move your hand to on top of the foot and ask them to press up against your hand. Repeat on the other foot. Scenario: Your neighbor is doing OK, but you still have some concerns. Instructor: What is the next step? Students: Evaluate motor strength. Motor Strength Key Points: 1. Isolating the muscle groups prevents the injured person from utilizing other muscle groups to conceal a weakness. 2. Remember one side will be stronger than the other for most people. 3. Mark your slate as you complete each muscle group to assure accuracy of your notations DAN Neurological Assessment 19

20 Skill: Coordination and Balance Required Equipment: 1. DAN Neurological Assessment Slate 2. Pencil Objective: 1. Assess and individual s coordination with a finger-nose-finger exercise 2. Determine presence of functional balance utilizing a straight walk and a Romberg test Rationale: Neurological injuries can affect the inner ear and the brain in ways that affect coordination and may make it difficult to stand, balance or walk. These tests will help determine if those areas have been affected. Skill Description: Coordination Coordination should be tested with the individual seated. Hold your finger about 18 inches (~9 centimeters) from the injured person s face Have them touch your finger with the index finger of one hand then touch their nose. Repeat action several times. Ask the individual to continue moving their finger between your finger and their nose but to close their eyes. Repeat sequence with the other hand. Minor differences between left and right sides are normal. Significant variations should be noted. Walking Have the individual look straight ahead and walk about 10 feet (3 meters) Stay close beside the individual, prepared to provide support should they lose their balance. Note if movements are uneven and/or require support. Teaching Tip: Our intent is only to assess. If an individual is unable to complete the coordination assessment or if other signs are evident that make walking questionable, skip this assessment and note why on the slate. Romberg If the individual was able to walk smoothly and without assistance and you are in a stable environment (not on a boat), complete the Romberg test. Have the individual stand with their feet together and raised arms out to the side. Instruct them to close their eyes and remain in that position for 60 seconds. Be prepared to support or catch them if they shows signs of falling. 20 Neurological Assessment DAN

21 Teaching Tip: The Sharpened Romberg is not a required skill. If you or a student volunteer would like to demonstrate it, provide close assistance in case balance is lost. Wobbling is normal, even for neurologically normal individuals, during this assessment. It should not be allowed to progress to falling. Scenario: EMS has not arrived but should be there any minute now. Your neighbor is getting restless and wants to get up. Instructor: What can you do? Students: Do a coordination assessment then walk across the room and back with them. Coordination and Balance Key Points 1. Coordination should be tested with the individual seated. 2. Stay close to the individual while they are walking and be prepared to provide assistance 3. If they start to should fall, assist them gently to the floor. Do not try to catch them as it may cause injury to one or both of you. DAN Neurological Assessment 21

22 Neurological Assessment Provider Assessment The following questions have only one correct answer unless otherwise indicated. 1. The brain, spinal cord and nerves make up the: a. Circulatory system b. Respiratory system c. Nervous system d. Skeletal system 2. Stroke symptoms include: a. inability to speak or understand b. visual disturbances c. sudden loss of motor function d. all of the above 3. Stroke is the number one cause of long term disability a. True b. False 4. F-A-S-T stands for a. Facts, attitude, sensitivity, talent b. Face, arms, speech, time c. Feet, arms, spine, toes d. Face, ankles, stability, touch 5. F-A-S-T is a quick assessment to determine if a neurological injury is a possibility. If any portion of the assessment shows deficits, EMS should be called immediately a. True b. False 6. Decompression illness includes both air gas embolism and decompression sickness. a. True b. False 7. Some of the most common warning signs of decompression illness include: a. Pain, numbness and tingling b. Dizziness and vertigo c. Fatigue d. All of the above 8. Which one of the following is not an area evaluated as part of a neurological assessment? a. Mental Function b. Coordination c. Cranial Nerves d. Skin Sensation 9. The tests to assess mental function in the neurological assessment include: a. Coordination and flexibility b. Memory and speech c. SAT scores d. None of the above 10. Testing an injured person s motor function includes providing pressure that they must resist and evaluating if there is a difference in strength from one side to the other. a. True b. False 11. Motor functions may be classified as normal, evidence of weakness, or paralysis. a. True b. False 22 Neurological Assessment DAN

23 12. Taking a history helps determine if signs and symptoms present may be due to a previous injury or illness. a. True b. False 13. If the injury may be related to a scuba diving incident, you need to document: a. All dives for 24 hours before the injury b. Symptom onset time c. Pre-existing conditions d. All of the above 14. Conducting a neurological assessment may convince an injured individual of the need for oxygen first aid. a. True b. False 15. Testing an injured person s mental function includes asking the patient to count backward from 100 by. a. 2s b. 3s c. 7s d. 9s 16. Tests of an injured person s cranial nerves include: a. Eye Control b. Facial Control c. Hearing d. All of the above 17. Assuming you are a long distance from emergency help, how often should you repeat an on-site neurological assessment? Every minutes. a. 15 b. 30 c. 60 d. Never 18. Neurological symptoms tend to be fixed when they develop and never change, until definitive treatment is begun. a. True b. False 19. Information gathered during a neurological assessment helps a patient physician understand the extent of the injury and determine how it has changed over time. a. True b. False 20. Retraining as a DAN Neurological Assessment provider is required every 36 months: a. True b. False DAN Neurological Assessment 23

24 I have reviewed this examination with the course instructor. I understand the correct response as indicated by my initials. Any questions regarding this examination and the contents of this course have been answered to my satisfaction. Student signature Date 24 Neurological Assessment DAN

25 Neurological Assessment Provider Answer Key I have reviewed this examination with the course instructor. I understand the correct response as indicated by my initials. Any questions regarding this examination and the contents of this course have been answered to my satisfaction. Student signature Date DAN Neurological Assessment 25

26 DAN Neurological Assessment Provider Course Quick Reference Chart 1. Registration and Introductions a. Course registration forms b. Statement of Understanding c. Completion of course roster student information 2. Knowledge Development Session [Choose one of these methods.] a. DAN Neurological Assessment video (40 minutes) b. DAN Neurological Assessment online knowledge development 3. Skills Development Session a. F-A-S-T b. History c. Vital Signs d. Mental Function e. Cranial Nerves f. Motor Function g. Coordination and Balance 4. Examination and Review 5. Present temporary DAN Neurological Assessment Provider certification printout if utilized. 6. Additional time for knowledge and skill remediation for individuals requiring additional practice. 7. Enter your student roster. Options: a. on-line b. fax your paper roster to DAN Education c. PDF 26 Neurological Assessment DAN