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
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.
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
◦ Intimidating 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 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.
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 15 X X
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
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?
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)
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)
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
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)
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)
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)
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.
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.
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009
The Providence Medical Foundation
The Providence Medical Foundation
The Providence Brain Institute
NIHSS T i i
NIHSS T i i
NIHSS Training
NIHSS Training
1a. Level of
C i
0 = Alert
Consciousness 1 = Sleepy but arouses
2 = Can’t stay awake
3 = No purposeful
response
1b. Questions 0 = Both correct
(month, age) 1 = One correct
2 = Neither correct
1c. Commands 0 = Obeys both
(close eyes, make fist) 1 = Obeys one
2 = Obeys neither
S f
S f
Safety
Safety
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
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
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
S f
S f
Safety
Safety
5a. Arm Weakness – Lt
0 = No drift1 = Drifts down does not hit bed
5b. Arm Weakness – Rt
(pt holds arm at 90
0if
sitting 45
0if s pine)
1 = Drifts down, does not hit bed 2 =Drifts down to hit bed
3 =Can move but can’t lift
sitting, 45
0if supine)
10 sec.
4 = No movement
X = Untestable (joint fused, etc)
6a. Leg Weakness– Lt
0 = No drift1 = Drifts down does not hit bed
6b. Leg Weakness– Rt
(pt holds leg straight out if
sitting 30
0if s pine)
1 = Drifts down, does not hit bed 2 =Drifts down to hit bed
3 =Can move but can’t lift
sitting, 30
0if supine)
5 sec.
4 = No movement
X = Untestable (joint fused, etc)
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
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
Safety
Safety
C l
C l Mi Mi dd
Commonly
Commonly Mis Mis--scored scored
8. Sensation
(pin prick face, arm, leg –
id )
0 = Normal
1 = Decreased sensation
compare 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 name
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
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
C l
C l Mi Mi dd
Commonly
Commonly Mis Mis--scored scored
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.
Safety
Safety
C l
C l Mi Mi dd
Commonly
Commonly Mis Mis--scored scored
http://www.strokeassociation.org/presenter.jhtml?identifier=3023009
B d id S ll S
B d id S ll S
Bedside Swallow Screen
Bedside Swallow Screen
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?
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!
Anterior Cerebral Artery
Middle Cerebral Artery
Posterior Cerebral Artery
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.
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.
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.
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.
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!
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
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