NIH Stroke Scale In Plain E li h English
Sandy Dancer, RN, MSN, ANP-C ANP C Providence Brain Institute Providence Portland Medical Center
I have no conflicts of interest to disclose. disclose
Preferred assessment tool for Primary Stroke Center certification Required for most stroke clinical trials
Infrequent users of NIHSS find it: ◦ Difficult to use ◦ Time consuming ◦ Intimidating
So, we simplified it:
◦ Developed by multidisciplinary team ◦ Translated neuro terminology ◦ No deleted components or changes to scoring
NIH Stroke Scale in plain English 3. Visual Fields ( h eyes open, count (Both 1/2/5 fingers/detect movement, 4 visual fields)
7. Coordination (Finger-to-nose, heelto-shin) Score only if not caused by weakness.
0=Normal visual fields 1 li d upper or lower 1=Blind l field fi ld one side. 2=Blind upper & lower field one side. 3=Blind in both eyes/4 y fields
0=Normal or no movement 1=Clumsy in one limb 2=Clumsy in two limbs
NIH Stroke Scale 3. Visual Fields ( (Introduce d visual i l stimulus/threat to pt’s visual field quadrants)
7. Limb Ataxia (Finger-nose, heel down shin)
0 = No visual loss 1 = Partial Hemianopia 2 = Complete Hemianopia 3 = Bilateral Hemianopia (blind)
0 = No ataxia 1 = Present in one limb 2 = Present in two limbs
Journal of Neuroscience Nursing
Volunteer RN’s AHA NIHSS training DVD Certification video patients NIHSS vs. NIHSS-PE NIHSS NIHSS-PE
Novice
16
X
X
Competent 15
X
X
Expert
X
X
15
NIHSSNIHSS -PE: Reliable and Valid Reliability
NIHSS
NIHSS-PE
Omega Heise & Bohrnstedt
0.964
0.974
Alpha Cronbach
0.854
0.849
Validity Concurrent Validity (Total Score Correlation of SS SS) NIHSS-PE to NIHSS) Heise & Bohrnstedt Validity (Correlation with 1st factor)
NIHSS ------0.979
NIHSS-PE NIHSS PE 0.977 0.977
Can naïve users of the NIHSS-PE (ie, rural ED MD/RN’s) get reliable scores to communicate with telestroke or other referral centers,
with little to no training?
Hypotheses 1. Trained will perform better than untrained on both scales. (Trained > Untrained) 2. NIHSS-PE will perform at least as well as NIHSS. SS (NIHSS-PE > NIHSS)
3. Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE = Trained NIHSS)
Study Design NIHSS NIHSS-PE
Trained T i d 31* (25 4%) (25.4%) 31** (25 4%) (25.4%)
Untrained U t i d 30 (24 5%) (24.5%) 30 (24 5%) (24.5%)
*AHA DVD (55 min) **Providence Stroke Team Power Point (13 min)
Methods
Patients #1,3,5 #1 3 5 (AHA NIHSS certification DVD) Gold standard: Expert panel Test group: Univ. of Portland Nursing students Analysis per General Linear Model
Results: Trained vs. Untrained (Deviation=|Participant p score - Expert p score|) Pt # (Expert score)
Pt 1 (5) n
Mean SD
Pt 3 (7)
Pt 5 (12)
Overall
Mean
SD
Mean
SD
Mean
SD
Sig 0.011
Untrained
60 2.5
2.4
3.4
2.7
4.6
2.4
3.5
2.5
T i d Trained
62 2.8 28
15 1.5
21 2.1
22 2.2
33 3.3
27 2.7
27 2.7
23 2.3
Hypothesis 1:Trained will perform better than untrained on both scales scales. (Trained > Untrained)
Results: NIHSSNIHSS-PE vs. NIHSS (Deviation=|Participant p score - Expert p score|) Pt # (Expert score)
Pt 1 (5) n
Mean SD
Pt 3 (7)
Pt 5 (12)
Overall
Mean
SD
Mean
SD
Mean
SD
Sig 0.033
NIHSS-PE
61 2.3
1.3
2.0
2.0
4.1
2.7
2.8
2.1
NIHSS
61 3.0 30
25 2.5
35 3.5
28 2.8
37 3.7
26 2.6
34 3.4
27 2.7
Hypothesis 2: NIHSS-PE will perform at least as well as NIHSS NIHSS. (NIHSS-PE > NIHSS)
Results: Untrained NIHSS NIHSS-PE vs. Trained NIHSS (Deviation=|Participant p score - Expert p score|) Pt # (Expert score)
Pt 1 (5) n
Mean SD
Pt 3 (7)
Pt 5 (12)
Overall
Mean
SD
Mean
SD
Mean
SD
Sig 0.176
NIHSS-T
31 3.0
1.7
2.6
2.3
3.0
2.9
2.9
2.3
NIHSS PE T NIHSS-PE-T
31 2.7 27
14 1.4
16 1.6
21 2.1
36 3.6
26 2.6
26 2.6
22 2.2
NIHSS-U
30 3.1
3.2
4.4
3.1
4.4
2.1
4.0
2.9
NIHSS-PE-U
30 2.0
1.1
2.5
1.8
4.7
2.8
3.0
2.0
Hypothesis 3: Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE = Trained NIHSS)
Conclusions
Phase I: The NIHSS-PE is reliable and valid compared to the NIHSS. Phase II: With minimal i i l ttraining, i i infrequent or novice users of the NIHSS-PE NIHSS PE can get reliable scores of stroke severity.
Implications
We hope that this user-friendly version will make the NIHSS more accessible to rural and small ll sites, it allowing ll i more confident fid t assessment of stroke patients.
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009
The Providence Medical Foundation The Providence Brain Institute
NIHSS Training T i i
1a. Level of C Consciousness i
0 = Alert 1 = Sleepy but arouses 2 = Can’t stay awake 3 = No purposeful response
1b. Questions (month, age)
0 = Both correct 1 = One correct 2 = Neither correct
1c. Commands (close eyes, make fist)
0 = Obeys both 1 = Obeys one 2 = Obeys neither
S f Safety
2. Lateral Gaze (eyes open, eyes follow examiners fingers/face side-to-side)
0 = Normal side-to-side eye movementt 1 = Partial side-to-side eye movement 2 = No side-to-side eye movement
3. Visual Fields (both eyes open, count 1/2/5 fingers/detect movement 4 visual movement, quadrants)
0 = Normal visual fields 1 = Blind 1 quadrant 2 = Blind 2 quadrants 3 = Blind in both eyes/4 quadrants
4. Facial Weakness (smile/grimace, raise eyebrows, squeeze eyes shut)
0 = Normal 1 = Mild droop with smile 2 = Obvious droop at rest 3 = Upper & lower face weak
S f Safety
5a. Arm Weakness – Lt 5b. Arm Weakness – Rt (pt holds arm at 900 if sitting 450 if supine) sitting, s pine) 10 sec.
0 = No drift 1 = Drifts down down, does not hit bed 2 =Drifts down to hit bed 3 =Can move but can’t lift 4 = No movement X = Untestable (joint fused, etc)
6a. Leg Weakness– Lt 6b. Leg Weakness– Rt (pt holds leg straight out if sitting 300 if supine) sitting, s pine) 5 sec.
0 = No drift 1 = Drifts down down, does not hit bed 2 =Drifts down to hit bed 3 =Can move but can’t lift 4 = No movement X = Untestable (joint fused, etc)
7. Coordination (Finger-to-nose, heel to shin.) hi ) S Score only l if greater than weakness.
0 = Normal or paralyzed 1 = Clumsy in one limb 2 = Clumsy in two limbs
7. Coordination (Finger-to-nose, heel to shin.) hi ) S Score only l if greater than weakness.
0 = Normal or paralyzed 1 = Clumsy in one limb 2 = Clumsy in two limbs
Safety C Commonly l Mis Mi -scored Misd
8. Sensation 0 = Normal (pin prick face, arm, leg – 1 = Decreased sensation compare sides) id ) 2 = Can’t feel, no pain withdrawal
For the Speech sections as appropriate ◦ Intubated patients can write ◦ Give blind patients objects to name
9. L 9 Language (intubated pt can write. Give blind pt objects to name)
0=N Normall llanguage 1 = Abnormal but understandable 2 = Incoherent 3 = Mute/Coma
10. D 10 Dysarthria th i ((slurring) l i ) (Reads / repeats words)
0=N Normall articulation ti l ti 1 = Slurs but understandable 2 = Slurs unintelligibly X = Intubated/phys barrier
C Commonly l Mis Mi -scored Misd
11. Neglect (Ignores one side vision/touch on both sides at once)
0 = Normal attention 1 = Neglects vision or sensation 2 = ignores one side of space; doesn’t recognize arm as own.
Safety C Commonly l Mis Mi -scored Misd
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009
B d id S Bedside Swallow ll S Screen
What the heck RU testing Or What h does d that h mean?
1a. Level of Consciousness
1b. Questions (month, age)
0= Alert 1= Sleepy but arouses 1= Sleepy but arouses 2= Can’t stay awake 3= No purposeful response
0=Both correct 1=One correct /intubated 2=Neither correct
Noodle Questions. Can the brain process information? This is not a test of speech. Tests the f t l lobes frontal l b andd brain b i stem t (alertness). Patients who can’t process information - safety risk!
1c. Commands (Cl (Close eyes, make fist) k fi t)
0= Obeys both 1 Ob 1= Obeys one 2= Obeys neither
2. Lateral Gaze (Eyes open. Eyes follow examiners fingers/face examiners fingers/face side‐to‐side)
0= Normal side‐to‐side eye movement Cranial nerves III & VI. Rare 1= Partial side‐to‐side eye movement to lose up down movement so 2= No side‐to‐side eye movement 2= No side‐to‐side eye movement isn’tt tested. isn tested More common to lose side to side. Marker for brainstem injury. If I can’t see – safety risk!
Anterior Cerebral Artery
Middle Cerebral Artery
Posterior Cerebral Artery
Case Study #1
82 year old patient comes in to the ED with suspected stroke I alert Is l t and d oriented i t d iincluding l di month th and d age. Able to follow all commands Lateral gaze is intact. Visual fields are intact. No facial droop is noted. Has no movement to the right arm or leg. Right leg is old symptom for prior stroke. Right arm is new finding. Has decreased sensation to right arm and leg. Right leg decreased sensation is old. Speech is clear. No neglect noted to testing.
Case Study #2
26 year old patient comes in with slurred speech (you can understand her) Burry vision to right eye Right facial droop. You notice the facial droop with smile and talking. talking The numbness to the left arm lasted about two hours and then went away. N Now has h HA to the h right i h side id off head. h d Has no other findings. Symptoms started yesterday.
Case Study #3
71 year old patient comes into the ED with suspected stroke. Woke up with symptoms symptoms. Last up to BR at Patient had a stroke to the left MCA 3 years ago and has some residual deficits. Remember the MCA is the territory most commonly affected by stroke stroke. What might these be? Patient is alert and oriented. Has right facial droop noticeable at rest. H right Has i h arm weakness. k F Falls ll to b bed. d Has right leg weakness. Falls to bed. Coordination is as expected.
Case Study #3 Continued
Very slight decrease in sensation to right side of body. H expressive Has i aphasia h i att baseline b li – slurs l so b badly dl you can’t ’t understand him. No receptive aphasia. Patient writes & uses picture board. No neglected noted to testing testing. Symptoms are very similar to how patient presented with stroke 3 years ago. What should I be considering in the differential? Note – patient has had a cough for the last week which is new for him.
Case Study #4
The above patient with all the same history and symptoms but hasn’t hasn t had a cough cough, and awoke in his usual state of pretty good health. At breakfast this am (0730) our patient started to exhibit increased symptoms of right sided weakness to the point that he couldn’t get his fork to his mouth or pick up his pills to take with breakfast. He went to stand to call 911 and fell down. down He is now in your ED at 0815 after his wife called 911. Good job wife!
Case Study #5
62 year old patient presents with sudden onset of dizziness, double vision vision, and unsteady gait gait. Also is very nauseated and just threw up in the waiting room while his wife was telling the receptionist about his symptoms. Symptoms started two hours ago. He also has a headache. BP 190/110. Wife says he has been on medication which has kept blood pressure in the 120-140 systolic range. When you get him back to a room he is Alert and oriented Follows all commands Lateral gaze intact Has field cut to left upper quad both eyes
Case Study #5 Continued
No facial droop N weakness No k noted t d tto arms or llegs Coordination is very off on the left in both arm and leg. Sensation is intact Speech is intact. Patient tells you he ran out of BP meds a week ago and kept forgetting to pick up refill. No neglect noted
