Providence Brain Institute Providence Portland Medical Center
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1 NIH Stroke Scale In Plain English Sandy Dancer, RN, MSN, ANP-C Sandy Dancer, RN, MSN, ANP C Providence Brain Institute Providence Portland Medical Center
2 I have no conflicts of interest to disclose.
3
4 Preferred assessment tool for Primary Stroke Center certification Required for most stroke clinical trials
5 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
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7 NIH Stroke Scale in plain English 3. Visual Fields (Both eyes open, count 1/2/5 fingers/detect movement, 4 visual fields) 0=Normal visual fields 1=Blind upper or lower field one side. 2=Blind upper & lower field one side. 3=Blind in both eyes/4 fields 3. Visual Fields (Introduce visual stimulus/threat to pt s visual field quadrants) NIH Stroke Scale 0 = No visual loss 1 = Partial Hemianopia 2 = Complete Hemianopia 3 = Bilateral Hemianopia (blind) 7. Coordination (Finger-to-nose, heelto-shin) Score only if not caused by weakness. 0=Normal or no movement 1=Clumsy in one limb 2=Clumsy in two limbs 7. Limb Ataxia (Finger-nose, heel down shin) 0 = No ataxia 1 = Present in one limb 2 = Present in two limbs
8 Journal of Neuroscience Nursing
9 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 15 X X
10 NIHSS-PE: Reliable and Valid Reliability NIHSS NIHSS-PE Omega Heise & Bohrnstedt Alpha Cronbach Validity NIHSS NIHSS-PE Concurrent Validity (Total Score Correlation of NIHSS-PE to NIHSS) Heise & Bohrnstedt Validity (Correlation with 1 st factor)
11 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?
12 Hypotheses 1. Trained will perform better than untrained on both scales. (Trained > Untrained) 2. NIHSS-PE will perform at least as well as NIHSS. (NIHSS-PE > NIHSS) 3. Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE = Trained NIHSS)
13 Study Design Trained Untrained NIHSS 31* 30 (25.4%) (24.5%) NIHSS-PE 31** 30 (25.4%) (24.5%) *AHA DVD (55 min) **Providence Stroke Team Power Point (13 min)
14 Methods Patients#135(AHANIHSScertificationDVD) #1,3,5 Gold standard: Expert panel Test group: Univ. of Portland Nursing students Analysis per General Linear Model
15 Results: Trained vs. Untrained (Deviation= Participant score -Expert score ) Pt # (Expert score) Pt 1 (5) Pt 3 (7) Pt 5 (12) Overall n Mean SD Mean SD Mean SD Mean SD Sig Untrained Trained Hypothesis 1:Trained will perform better than untrained on both scales. (Trained > Untrained)
16 Results: NIHSS-PE vs. NIHSS (Deviation= Participant score -Expert score ) Pt # (Expert score) Pt 1 (5) Pt 3 (7) Pt 5 (12) Overall n Mean SD Mean SD Mean SD Mean SD Sig NIHSS-PE NIHSS Hypothesis 2: NIHSS-PE will perform at least as well as NIHSS. (NIHSS-PE > NIHSS)
17 Results: Untrained NIHSS-PE vs. Trained NIHSS (Deviation= Participant score -Expert score ) Pt # (Expert score) Pt 1 (5) Pt 3 (7) Pt 5 (12) Overall n Mean SD Mean SD Mean SD Mean SD Sig NIHSS-T NIHSS-PE-T NIHSS-U NIHSS-PE-U Hypothesis 3: Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE = Trained NIHSS)
18 Conclusions Phase I: The NIHSS-PE is reliable and valid compared to the NIHSS. Phase II: With minimal i training, i infrequent or novice users of the NIHSS-PE can get reliable scores of stroke severity.
19 Implications We hope that this user-friendly version will make the NIHSS more accessible to rural and small sites, allowing more confident assessment of stroke patients.
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21 The Providence Medical Foundation The Providence Medical Foundation The Providence Brain Institute
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23 NIHSS Training i
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25 1a. Level of Consciousness 0 = Alert 1 = Sleepy but arouses 2 = Can t stay awake 3 = No purposeful response
26 1b. Questions 0 = Both correct (month, age) 1 = One correct 2 = Neither correct
27 1c. Commands 0 = Obeys both (close eyes, make fist) 1 = Obeys one 2 = Obeys neither
28 Safety
29 2. Lateral Gaze 0 = Normal side-to-side (eyes open, eyes follow eye movement examiners fingers/face 1 = Partial side-to-side side-to-side) eye movement 2 = No side-to-side eye movement
30 3. Visual Fields 0 = Normal visual fields (both eyes open, count 1 = Blind 1 quadrant 1/2/5 fingers/detect 2 = Blind 2 quadrants movement, 4 visual 3 = Blind in both eyes/4 quadrants) quadrants
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32 4. Facial Weakness 0 = Normal (smile/grimace, raise 1 = Mild droop with smile eyebrows, squeeze eyes 2 = Obvious droop at rest shut) 3 = Upper & lower face weak
33 Safety
34 5a. Arm Weakness Lt 0 = No drift 5b. Arm Weakness Rt (pt holds arm at 90 0 if sitting, 45 0 if supine) 10 sec. 1 = Drifts 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)
35 6a. Leg Weakness Lt 0 = No drift 6b. Leg Weakness Rt (pt holds leg straight out if sitting, 30 0 if supine) 5 sec. 1 = Drifts 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)
36 7. Coordination (Finger-to-nose, heel to shin.) Score only if greater than weakness. 0 = Normal or paralyzed 1 = Clumsy in one limb 2 = Clumsy in two limbs
37 7. Coordination (Finger-to-nose, heel to shin.) Score only if greater than weakness. 0 = Normal or paralyzed 1 = Clumsy in one limb 2 = Clumsy in two limbs
38 Safety Commonly Mis-scoredscored
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40 8. Sensation (pin prick face, arm, leg compare sides) 0 = Normal 1 = Decreased sensation 2 = Can t feel, no pain withdrawal
41 For the Speech sections as appropriate For the Speech sections as appropriate Intubated patients can write Give blind patients objects to name
42 9. Language 0 = Normal language (intubated pt can write. 1 = Abnormal but Give blind pt objects to understandable name) 2 = Incoherent 3 = Mute/Coma
43 10. Dysarthria (slurring) 0 = Normal articulation (Reads / repeats words) 1 = Slurs but understandable 2 = Slurs unintelligibly X = Intubated/phys barrier
44 Commonly Mis-scoredscored
45 11. Neglect 0 = Normal attention (Ignores one side 1 = Neglects vision or vision/touch on both sides sensation at once) 2 = ignores one side of space; doesn t recognize arm as own.
46 Safety Commonly Mis-scoredscored
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48
49 Bedside Swallow Screen
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51 What the heck RU testing Or What does that mean?
52 1a. Level of Consciousness 1b. Questions (month, age) 1c. Commands (Close eyes, make fist) 2. Lateral Gaze (Eyes open. Eyes follow examiners fingers/face side to side) 0= Alert 1= Sleepy but arouses 2= Can t stay awake 3= No purposeful response Noodle Questions. Can the brain process information? This is not a test of speech. Tests the 0=Both correct frontal llobes and dbrain stem 1=One correct /intubated (alertness). 2=Neither correct Patients who can t process 0= Obeys both information - safety risk! 1= Obeys one 2= Obeys neither 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 isn t tested. More common to lose side to side. Marker for brainstem injury. If I can t see safety risk!
53 Anterior Cerebral Artery
54 Middle Cerebral Artery
55 Posterior Cerebral Artery
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57
58 Case Study #1 82 year old patient comes in to the ED with suspected stroke Is alert and oriented including month and 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.
59 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. The numbness to the left arm lasted about two hours and then went away. Now has HA to the right side of head. Has no other findings. Symptoms started yesterday.
60 Case Study #3 71 year old patient comes into the ED with suspected stroke. Woke up with 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. What might these be? Patient is alert and oriented. Has right facial droop noticeable at rest. Has right arm weakness. Falls to bed. Has right leg weakness. Falls to bed. Coordination is as expected.
61 Case Study #3 Continued Very slight decrease in sensation to right side of body. Has expressive aphasia at baseline slurs so badly you can t understand him. No receptive aphasia. Patient writes & uses picture board. No neglected noted to 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.
62 Case Study #4 The above patient with all the same history and symptoms but hasn t had a 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. He is now in your ED at 0815 after his wife called 911. Good job wife!
63 Case Study #5 62 year old patient presents with sudden onset of dizziness, double vision, and unsteady 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 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
64 Case Study #5 Continued No facial droop No weakness noted to arms or legs 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
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Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ( )
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Patient Identification. - - Pt. Date of Birth / / Hospital ( - ) Date of Exam / / Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months
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