NIH Stroke Scale In Plain ElihEnglish - Oregon Stroke Network

NIH Stroke Scale In Plain ElihEnglish Sandy Dancer, RN, MSN, ANPSandy Dancer, RN, MSN, ANP-C Providence Brain Institute Providence Portland Medical Ce...

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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