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NIH Stroke Scale In Plain

NIH Stroke Scale In Plain

E li h

E li h

English

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

I have no conflicts of interest to disclose

I have no conflicts of interest to disclose.

I have no conflicts of interest to disclose.

(3)
(4)

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

(5)

Infrequent users of NIHSS find it:

◦ Difficult to use

◦ Time consuming

◦ Intimidating Intimidating

So, we simplified it:

◦ Developed by multidisciplinary team

◦ Translated neuro terminology

◦ No deleted components or changes to scoring

(6)
(7)

NIH Stroke Scale in plain English NIH Stroke Scale

3. Visual Fields

( h

0=Normal visual fields

1 li d l fi ld

3. Visual Fields

( d i l

0 = No visual loss 1 = Partial Hemianopia (Both eyes open, count

1/2/5 fingers/detect movement, 4 visual fields)

1=Blind upper or lower field one side.

2=Blind upper & lower field one side.

3=Blind in both eyes/4 fields

(Introduce visual stimulus/threat to pt’s visual field quadrants)

1 Partial Hemianopia 2 = Complete Hemianopia 3 = Bilateral Hemianopia (blind)

y

7. Coordination (Finger-to-nose, heel- to-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 weakness.

(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

NIHSS--PE: Reliable and Valid PE: Reliable and Valid

Reliability NIHSS NIHSS-PE

Omega

Heise & Bohrnstedt 0.964 0.974

Alpha 0.854 0.849

Alpha

Cronbach 0.854 0.849

Validity NIHSS NIHSS-PE

Validity NIHSS NIHSS PE

Concurrent Validity

(Total Score Correlation of

SS SS) --- 0.977

NIHSS-PE to NIHSS)

Heise & Bohrnstedt Validity

(Correlation with 1st factor) 0.979 0.977

(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?

with little to no training?

(12)

Hypotheses

Hypotheses

Hypotheses

Hypotheses

1. 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

SS

NIHSS.

(NIHSS-PE > NIHSS)

3. Untrained NIHSS-PE will perform similarly to

trained NIHSS.

(Untrained NIHSS-PE =

Trained NIHSS)

(13)

Study Design

Study Design

T i d U t i d

Study Design

Study Design

Trained Untrained

NIHSS 31*

(25 4%) 30

(24 5%)

(25.4%) (24.5%)

NIHSS-PE 31**

(25 4%) 30

(24 5%)

(25.4%) (24.5%)

*AHA DVD (55 min)

**Providence Stroke Team Power Point (13 min)

(14)

Methods

Methods

Methods

Methods

Patients #1 3 5 (AHA NIHSS certification DVD)

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 Model

(15)

Results: Trained vs. Untrained

Results: Trained vs. Untrained

(Deviation=|Participant score

(Deviation=|Participant score -- Expert score|) pp Expert score|) pp

Pt # (Expert

score) Pt 1 (5) Pt 3 (7) Pt 5 (12) Overall score)

n Mean SD Mean SD Mean SD Mean SD Sig Untrained 60 2.5 2.4 3.4 2.7 4.6 2.4 3.5 2.5 0.011

T i d 62 2 8 1 5 2 1 2 2 3 3 2 7 2 7 2 3

Trained 62 2.8 1.5 2.1 2.2 3.3 2.7 2.7 2.3

Hypothesis 1:Trained will perform better than

untrained on both scales

untrained on both scales.

(Trained > Untrained)

(16)

Results: NIHSS

Results: NIHSS--PE vs. NIHSS PE vs. NIHSS

(Deviation=|Participant score

(Deviation=|Participant score -- Expert score|) pp Expert score|) pp

Pt # (Expert

score) Pt 1 (5) Pt 3 (7) Pt 5 (12) Overall score)

n Mean SD Mean SD Mean SD Mean SD Sig NIHSS-PE 61 2.3 1.3 2.0 2.0 4.1 2.7 2.8 2.1 0.033

NIHSS 61 3 0 2 5 3 5 2 8 3 7 2 6 3 4 2 7

NIHSS 61 3.0 2.5 3.5 2.8 3.7 2.6 3.4 2.7

Hypothesis 2: NIHSS-PE will perform at

least as well as NIHSS

least as well as NIHSS.

(NIHSS-PE > NIHSS)

(17)

Results: Untrained NIHSS

Results: Untrained NIHSS--PE vs. Trained NIHSS PE vs. Trained NIHSS

(Deviation=|Participant score

(Deviation=|Participant score -- Expert score|) pp Expert score|) pp

Pt # (Expert

score) Pt 1 (5) Pt 3 (7) Pt 5 (12) Overall score)

n Mean SD Mean SD Mean SD Mean SD Sig NIHSS-T 31 3.0 1.7 2.6 2.3 3.0 2.9 2.9 2.3 0.176 NIHSS PE T 31 2 7 1 4 1 6 2 1 3 6 2 6 2 6 2 2

NIHSS-PE-T 31 2.7 1.4 1.6 2.1 3.6 2.6 2.6 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)

(18)

Conclusions

Conclusions

Phase I:

Conclusions

Conclusions

The NIHSS-PE is reliable and

valid compared to the NIHSS.

Phase II:

With i i l t i i

With minimal training,

infrequent or novice users of

the NIHSS-PE can get reliable

the NIHSS PE can get reliable

scores of stroke severity.

(19)

Implications

Implications

Implications

Implications

We hope that this user-friendly version will

make the NIHSS more accessible to rural and

ll it ll i fid t

small sites, allowing more confident

assessment of stroke patients.

(20)

http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

(21)

The Providence Medical Foundation

The Providence Medical Foundation

The Providence Brain Institute

(22)
(23)

NIHSS T i i

NIHSS T i i

NIHSS Training

NIHSS Training

(24)
(25)

1a. Level of

C i

0 = Alert

Consciousness 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)

S f

S f

Safety

Safety

(29)

2. Lateral Gaze 0 = Normal side-to-side

(eyes open, eyes follow t

examiners fingers/face

side-to-side)

eye movement

1 = Partial side-to-side

eye movement

side-to-side) eye movement

2 = No side-to-side eye

movement

(30)

3. Visual Fields 0 = Normal visual fields

(both eyes open, count

1/2/5 fingers/detect

movement 4 visual

1 = Blind 1 quadrant

2 = Blind 2 quadrants

movement, 4 visual

quadrants) 3 = Blind in both eyes/4

quadrants

(31)
(32)

4. Facial Weakness 0 = Normal

(smile/grimace, raise

eyebrows, squeeze eyes

shut)

1 = Mild droop with smile

2 = Obvious droop at rest

shut)

3 = Upper & lower face

weak

(33)

S f

S f

Safety

Safety

(34)

5a. Arm Weakness – Lt

0 = No drift

1 = Drifts down does not hit bed

5b. Arm Weakness – Rt

(pt holds arm at 90

0

if

sitting 45

0

if s pine)

1 = Drifts down, does not hit bed 2 =Drifts down to hit bed

3 =Can move but can’t lift

sitting, 45

0

if supine)

10 sec.

4 = No movement

X = Untestable (joint fused, etc)

(35)

6a. Leg Weakness– Lt

0 = No drift

1 = Drifts down does not hit bed

6b. Leg Weakness– Rt

(pt holds leg straight out if

sitting 30

0

if s pine)

1 = Drifts down, does not hit bed 2 =Drifts down to hit bed

3 =Can move but can’t lift

sitting, 30

0

if supine)

5 sec.

4 = No movement

X = Untestable (joint fused, etc)

(36)

7. Coordination

(Finger-to-nose, heel to

hi ) S l if

0 = Normal or paralyzed

1 = Clumsy in one limb

shin.) Score only if

greater than weakness.

2 = Clumsy in two limbs

(37)

7. Coordination

(Finger-to-nose, heel to

hi ) S l if

0 = Normal or paralyzed

1 = Clumsy in one limb

shin.) Score only if

greater than weakness.

2 = Clumsy in two limbs

(38)

Safety

Safety

C l

C l Mi Mi dd

Commonly

Commonly Mis Mis--scored scored

(39)
(40)

8. Sensation

(pin prick face, arm, leg –

id )

0 = Normal

1 = Decreased sensation

compare sides) 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 L 0 N l l

9. Language

(intubated pt can write.

Give blind pt objects to

0 = Normal language

1 = Abnormal but

understandable

Give blind pt objects to

name)

understandable

2 = Incoherent

3 = Mute/Coma

3 = Mute/Coma

(43)

10 D th i ( l i ) 0 N l ti l ti

10. Dysarthria (slurring)

(Reads / repeats words)

0 = Normal articulation

1 = Slurs but

understandable

understandable

2 = Slurs unintelligibly

X = Intubated/phys barrier

X = Intubated/phys barrier

(44)

C l

C l Mi Mi dd

Commonly

Commonly Mis Mis--scored scored

(45)

11. Neglect 0 = Normal attention

(Ignores one side

vision/touch on both sides

at once)

1 = Neglects vision or

sensation

2 ignores one side of

at once) 2 = ignores one side of

space; doesn’t recognize

arm as own.

(46)

Safety

Safety

C l

C l Mi Mi dd

Commonly

Commonly Mis Mis--scored scored

(47)
(48)

http://www.strokeassociation.org/presenter.jhtml?identifier=3023009

(49)

B d id S ll S

B d id S ll S

Bedside Swallow Screen

Bedside Swallow Screen

(50)
(51)

What the heck RU testing

What the heck RU testing

What the heck RU testing

What the heck RU testing

Or

h d h Or

h d h

What does that mean?

What does that mean?

(52)

1a. Level of  Consciousness

0= Alert        

1= Sleepy but arouses Consciousness 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 f t l l b d b i t

frontal lobes and brain stem (alertness).

Patients who can’t process information - safety risk!

1b. Questions (month, age)

0=Both correct  

1=One correct /intubated 2=Neither correct

1c. Commands

(Cl k fi t)

0= Obeys both         1 Ob

(Close eyes, make fist) 1= Obeys one        2= Obeys neither  2. Lateral Gaze

(Eyes open. Eyes follow  examiners fingers/face

0= Normal side‐to‐side eye movement 1= Partial side‐to‐side eye movement 2= No side‐to‐side eye movement

Cranial nerves III & VI. Rare to lose up down movement so isn’t tested More common to examiners  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 injury.

If I can’t see – safety risk!

(53)

Anterior Cerebral Artery

(54)

Middle Cerebral Artery

(55)

Posterior Cerebral Artery

(56)
(57)
(58)

Case Study #1

Case Study #1

82 year old patient comes in to the ED with suspected stroke

I l t d i t d i l di th d

Case Study #1

Case Study #1

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

Case Study #2

26 year old patient comes in with slurred speech (you can understand her)

Case Study #2

Case Study #2

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 h HA h i h id f h d

Now has HA to the right side of head.

Has no other findings.

Symptoms started yesterday.

(60)

Case Study #3

Case Study #3

71 year old patient comes into the ED with suspected stroke.

Woke up with symptoms Last up to BR at

Case 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. 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 rest.

H i h k F ll b d

Has right arm weakness. Falls to bed.

Has right leg weakness. Falls to bed.

Coordination is as expected.

(61)

Case Study #3 Continued

Case Study #3 Continued

Very slight decrease in sensation to right side of body.

H i h i t b li l b dl ’t

Case Study #3 Continued

Case Study #3 Continued

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

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 him.

(62)

Case 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 pretty

Case Study #4

Case Study #4

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 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 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

Case Study #5

62 year old patient presents with sudden onset of dizziness, double vision and unsteady gait Also is very nauseated and

Case Study #5

Case Study #5

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 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

When you get him back to a room he is

Alert and oriented

Follows all commands

Lateral gaze intact

Lateral gaze intact

Has field cut to left upper quad both eyes

(64)

Case Study #5 Continued

Case Study #5 Continued

No facial droop

N k t d t l

Case Study #5 Continued

Case Study #5 Continued

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

(65)

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