NIH Stroke Scale In Plain ElihEnglish

1 NIH Stroke Scale In Plain NIH Stroke Scale In Plain ElihElihEnglishEnglishSandy Dancer, RN, MSN, ANP-CSandy Dancer, RN, MSN, ANPCP rovidence Brain InstituteProvidence Portland Medical CenterI have no conflicts of interest to discloseI have no conflicts of interest to discloseI have no conflicts of interest to have no conflicts of interest to disclose. Preferred assessment tool for Primary Stroke Preferred assessment tool for Primary Stroke Center certification Required for most Stroke clinical trials Required for most Stroke clinical trials Infrequent users of NIHSS find it: Difficult to use Time consuming IntimidatingIntimidating So, we simplified it: Developed by multidisciplinary team Translated neuro terminology No deleted components or changes to scoringNIH Stroke Scalein Plain EnglishNIH Stroke Scale3. Visual Fields(h0=Normal visual fields1lidlfild3. Visual Fields(d il0 = No visual loss1=Partial Hemianopia(Both eyes open, count 1/2/5 fingers/detect movement, 4 visual fields)1=Blind upper orlower field one upper &lower field one in both eyes/4 fields(Introduce visual stimulus/threat to pt s visual field quadrants)1 Partial Hemianopia2 = Complete Hemianopia3 = Bilateral Hemianopia (blind) (Finger-to-nose, heel-to-shin) Score onlyif not caused by weakness.))

2 0=Normal or no movement1=Clumsy in one limb2=Clumsy in two Ataxia(Finger-nose, heel down shin) 0 = No ataxia1 = Present in one limb2 = Present in two limbsweakness. Journal of Neuroscience Nursing Volunteer RN s AHA NIHSS training DVD Certification video patients NIHSS vs. NIHSS-PENIHSS NIHSS-PENovice16 XXCompetent 15 XXExpert15 XXNIHSSNIHSS--PE: Reliable and ValidPE: Reliable and ValidReliabilityNIHSSNIHSS-PEOmegaHeise & Validity(Total Score Correlation of SSSS) to NIHSS)Heise & Bohrnstedt Validity (Correlation with 1stfactor) na ve 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?with little to no training?HypothesesHypothesesHypothesesH ypotheses1. Trained will perform better than untrained on both scales.(Trained > Untrained)on both scales. (Trained > Untrained)2. NIHSS-PE will perform at least as well as SSNIHSS. (NIHSS-PE >NIHSS)3.

3 Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE = Trained NIHSS)Study DesignStudy DesignTi dUt i dStudy DesignStudy DesignTrained Untrained NIHSS31* (25 4%)30 (24 5%)( )( )NIHSS-PE31** (25 4%)30 (24 5%)( )( )*AHA DVD (55 min)**Providence Stroke Team Power Point (13 min)MethodsMethodsMethodsMethods Patients#135(AHANIHSS certificationDVD) Patients #1,3,5 (AHA NIHSS certification DVD) Gold standard: Expert panel Test group: Univ. of Portland Nursing students Test group: Univ. of Portland Nursing students Analysis per General Linear ModelResults: Trained vs. UntrainedResults: Trained vs. Untrained(Deviation=|Participant score (Deviation=|Participant score --Expert score|) Expert score|) ppppPt # (Expert score)Pt 1 (5)Pt 3 (7)Pt 5 (12)Overallscore)nMean SDMean SDMean SDMean SDSigUntrained60 1:Trained will perform better than untrained on both scalesuntrained on both scales. (Trained > Untrained)Results: NIHSSR esults: NIHSS--PE vs.

4 NIHSSPE vs. NIHSS(Deviation=|Participant score (Deviation=|Participant score --Expert score|) Expert score|) ppppPt # (Expert score)Pt 1 (5)Pt 3 (7)Pt 5 (12)Overallscore)nMean SDMean SDMean SDMean SDSigNIHSS-PE61 2: NIHSS-PE will perform at least as well as NIHSS least as well as NIHSS. (NIHSS-PE >NIHSS)Results: Untrained NIHSSR esults: Untrained NIHSS--PE vs. Trained NIHSSPE vs. Trained NIHSS(Deviation=|Participant score (Deviation=|Participant score --Expert score|) Expert score|) ppppPt # (Expert score)Pt 1 (5)Pt 3 (7)Pt 5 (12)Overallscore)nMean SDMean SDMean SDMean SDSigNIHSS-T31 3: Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE = Trained NIHSS)ConclusionsConclusions Phase I: ConclusionsConclusionsThe NIHSS-PE is reliable and valid compared to the NIHSS. Phase II: With ii lt iiWith minimal training, infrequent or novice users of the NIHSS-PE can get reliablethe NIHSSPE can get reliable scores of Stroke We hope that this user-friendly version will make the NIHSS more accessible to rural and ll itllifid tsmall sites, allowing more confident assessment of Stroke Providence Medical FoundationThe Providence Medical FoundationThe Providence Brain Institute NIHSS T i iNIHSS T i iNIHSS TrainingNIHSS Training1a.

5 Level of Ci0 = AlertConsciousness1 = Sleepy but arouses2 = Can t stay awake3 = No purposeful response1b. Questions0 = Both correct(month, age)1 = One correct2 = Neither correct1c. Commands0 = Obeys both(close eyes, make fist)1 = Obeys one2 = Obeys neitherSfSfSafetySafety2. Lateral Gaze0 = Normal side-to-side t(eyes open, eyes follow examiners fingers/face side-to-side)eye movement1 = Partial side-to-side eye movementside-to-side)eye movement2 = No side-to-side eye movement3. Visual Fields0 = Normal visual fields(both eyes open, count 1/2/5 fingers/detect movement 4 visual1 = Blind 1 quadrant2 = Blind 2 quadrantsmovement, 4 visual quadrants)3 = Blind in both eyes/4 quadrants4. Facial Weakness0 = Normal(smile/grimace, raise eyebrows, squeeze eyes shut)1 = Mild droop with smile2 = Obvious droop at restshut)3 = Upper &lower face weakSfSfSafetySafety5a. Arm Weakness Lt0 = No drift1 = Drifts down does not hit bed5b. Arm Weakness Rt(pt holds arm at 900if sitting 450if s pine)1 = Drifts down, does not hit bed2 =Drifts down to hit bed3 =Can move but can t liftsitting, 450if supine) 10 = No movementX = Untestable (joint fused, etc)6a.

6 Leg Weakness Lt0 = No drift1 = Drifts down does not hit bed6b. Leg Weakness Rt(pt holds leg straight out if sitting 300if s pine)1 = Drifts down, does not hit bed2 =Drifts down to hit bed3 =Can move but can t liftsitting, 300 if supine) 5 = No movementX = Untestable (joint fused, etc)7. Coordination(Finger-to-nose, heel to hi ) Slif0 = Normal or paralyzed 1 = Clumsy in one limbshin.) Score onlyif greater than = Clumsy in two limbs7. Coordination(Finger-to-nose, heel to hi ) Slif0 = Normal or paralyzed1 = Clumsy in one limbshin.) Score onlyif greater than = Clumsy in two limbsSafetySafetyClClMiMiddCommonly Commonly MisMis--scoredscored8. Sensation (pin prick face, arm, leg id )0 = Normal1 = Decreased sensationcompare sides)2 = Can t feel, no pain withdrawal For the Speech sections as appropriate For the Speech sections as appropriate Intubated patients can write Give blind patients objects to name9L0 Nll9. Language(intubated pt can write.

7 Give blind pt objects to0 = Normal language1 = Abnormal but understandableGive blind pt objects to name)understandable2 = Incoherent3 = Mute/Coma3 = Mute/Coma10 Dth i ( li)0 Nltilti10. Dysarthria (slurring)(Reads / repeats words)0 = Normal articulation1 = Slurs but understandableunderstandable2 = Slurs unintelligibly X = Intubated/phys barrierX = Intubated/phys barrierClClMiMiddCommonly Commonly MisMis--scoredscored11. Neglect0 = Normal attention(Ignores one side vision/touch on both sides at once)1 = Neglects vision or sensation2ignores one side ofat once)2 = ignores one side of space; doesn t recognize arm as Commonly MisMis-- S ll SBdid S ll SBedside Swallow ScreenBedside Swallow ScreenWhat the heck RU testingWhat the heck RU testingWhat the heck RU testingWhat the heck RU testingOrOrhd hhd hWhat does that mean?What does that mean?1a. Level of Consciousness0= Alert 1=SleepybutarousesConsciousness1= Sleepy but arouses2= Can t stay awake 3= No purposeful responseNoodle Questions.

8 Can the brain process information? This is not a test of speech. Tests the ftllb dbitfrontal lobes and brain stem (alertness).Patients who can t process information - safety risk!1b. Questions(month, age)0=Both correct 1=One correct /intubated2=Neither correct1c. Commands(Clkfi t)0= Obeys both 1Ob(Close eyes, make fist)1= Obeys one 2= Obeys neither 2. Lateral Gaze(Eyes open. Eyes follow examinersfingers/face0= Normal side to side eye movement1= Partial side to side eye movement2=Noside to sideeyemovementCranial nerves III & VI. Rare to lose up down movement so isn t tested More common toexaminers fingers/face side to side)2= No side to side eye movement isn t tested. More common to lose side to side. Marker for brainstem I can t see safety risk!Anterior Cerebral ArteryMiddle Cerebral ArteryPosterior Cerebral ArteryCase Study #1 Case Study #1 82 year old patient comes in to the ED with suspected strokeIlt ditdildith dCase Study #1 Case Study #1 Is alert and oriented including month and age.

9 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 Study #2 Case Study #2 26 year old patient comes in with slurred speech (you can understand her)Case Study #2 Case Study #2understand her) Burry vision to right eye Right facial droop. You notice the facial droop with smile and talkingtalking. The numbness to the left arm lasted about two hours and then went away. NhHA hihidfhd Now has HA to the right side of head. Has no other findings. Symptoms started Study #3 Case Study #3 71 year old patient comes into the ED with suspected Stroke . Woke up with symptoms Last up to BR atCase Study #3 Case Study #3 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.

10 Remember the MCA is the territory most commonly affected by Stroke What might these be?most commonly affected by Stroke . What might these be? Patient is alert and oriented. Has right facial droop noticeable at Fll bd Has right arm weakness. Falls to bed. Has right leg weakness. Falls to bed. Coordination is as expected. Case Study #3 ContinuedCase Study #3 Continued Very slight decrease in sensation to right side of tCase Study #3 ContinuedCase Study #3 Continued Has expressive aphasia at baseline slurs so badly you can t understand him. No receptive aphasia. Patient writes & uses picture neglected noted to testing 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?differential? Note patient has had a cough for the last week which is new for Study #4 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 prettyCase Study #4 Case Study #4but hasn t had a cough, and awoke in his usual state of pretty good health.