NIH Stroke Scale In Plain ElihEnglish - Oregon Stroke · PDF fileNIH Stroke Scale In Plain...

NIH Stroke Scale In Plain NIH Stroke Scale In Plain E li hE li hEnglishEnglish

Sandy Dancer, RN, MSN, ANP-CSandy Dancer, RN, MSN, ANP CProvidence Brain Institute

Providence Portland Medical Center

I have no conflicts of interest to discloseI have no conflicts of interest to discloseI 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◦ IntimidatingIntimidating

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 fields1 li d l fi ld

3. Visual Fields( d i l

0 = No visual loss1 = 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 Hemianopia2 = Complete Hemianopia3 = Bilateral Hemianopia (blind)

y

7. Coordination(Finger-to-nose, heel-to-shin) Score only if not caused by weakness.

0=Normal or no movement1=Clumsy in one limb2=Clumsy in two limbs

7. Limb Ataxia(Finger-nose, heel down shin)

0 = No ataxia1 = Present in one limb2 = 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

NIHSSNIHSS--PE: Reliable and ValidPE: Reliable and ValidReliability NIHSS NIHSS-PE

OmegaHeise & Bohrnstedt

0.964 0.974

Alpha 0.854 0.849AlphaCronbach

0.854 0.849

Validity NIHSS NIHSS-PEValidity 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?

HypothesesHypothesesHypothesesHypotheses1. 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. Untrained NIHSS-PE will perform similarly to trained NIHSS. (Untrained NIHSS-PE =

Trained NIHSS)

Study DesignStudy Design

T i d U t i d

Study DesignStudy 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)

MethodsMethodsMethodsMethods

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. UntrainedResults: Trained vs. Untrained(Deviation=|Participant score (Deviation=|Participant score -- Expert score|) Expert score|) pp pp

Pt # (Expert score)

Pt 1 (5) Pt 3 (7) Pt 5 (12) Overallscore)

n Mean SD Mean SD Mean SD Mean SD SigUntrained 60 2.5 2.4 3.4 2.7 4.6 2.4 3.5 2.5 0.011T i d 62 2 8 1 5 2 1 2 2 3 3 2 7 2 7 2 3Trained 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 scalesuntrained on both scales. (Trained > Untrained)

Results: NIHSSResults: NIHSS--PE vs. NIHSSPE vs. NIHSS(Deviation=|Participant score (Deviation=|Participant score -- Expert score|) Expert score|) pp pp

Pt # (Expert score)

Pt 1 (5) Pt 3 (7) Pt 5 (12) Overallscore)

n Mean SD Mean SD Mean SD Mean SD SigNIHSS-PE 61 2.3 1.3 2.0 2.0 4.1 2.7 2.8 2.1 0.033NIHSS 61 3 0 2 5 3 5 2 8 3 7 2 6 3 4 2 7NIHSS 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 NIHSSleast as well as NIHSS. (NIHSS-PE > NIHSS)

Results: Untrained NIHSSResults: Untrained NIHSS--PE vs. Trained NIHSSPE vs. Trained NIHSS(Deviation=|Participant score (Deviation=|Participant score -- Expert score|) Expert score|) pp pp

Pt # (Expert score)

Pt 1 (5) Pt 3 (7) Pt 5 (12) Overallscore)

n Mean SD Mean SD Mean SD Mean SD SigNIHSS-T 31 3.0 1.7 2.6 2.3 3.0 2.9 2.9 2.3 0.176NIHSS PE T 31 2 7 1 4 1 6 2 1 3 6 2 6 2 6 2 2NIHSS-PE-T 31 2.7 1.4 1.6 2.1 3.6 2.6 2.6 2.2NIHSS-U 30 3.1 3.2 4.4 3.1 4.4 2.1 4.0 2.9NIHSS-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)

ConclusionsConclusions Phase I:

ConclusionsConclusions

The NIHSS-PE is reliable and valid compared to the NIHSS.

Phase II: With i i l t i iWith minimal training, infrequent or novice users of the NIHSS-PE can get reliablethe NIHSS PE can get reliable scores of stroke severity.

ImplicationsImplicationsImplicationsImplications

We hope that this user-friendly version will make the NIHSS more accessible to rural and

ll it ll i fid tsmall sites, allowing more confident assessment of stroke patients.

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

The Providence Medical FoundationThe Providence Medical FoundationThe Providence Brain Institute

NIHSS T i iNIHSS T i iNIHSS TrainingNIHSS Training

1a. Level of C i

0 = AlertConsciousness 1 = Sleepy but arouses

2 = Can’t stay awake3 = 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 fS fSafetySafety

2. Lateral Gaze 0 = 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 movement

3. Visual Fields 0 = Normal visual fields(both eyes open, count 1/2/5 fingers/detect movement 4 visual

1 = Blind 1 quadrant2 = 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 smile2 = Obvious droop at rest

shut) 3 = Upper & lower face weak

S fS fSafetySafety

5a. Arm Weakness – Lt 0 = No drift1 = Drifts down does not hit bed5b. Arm Weakness – Rt

(pt holds arm at 900 if sitting 450 if s pine)

1 = Drifts down, does not hit bed2 =Drifts down to hit bed3 =Can move but can’t lift

sitting, 450 if supine) 10 sec.

4 = No movementX = Untestable (joint fused, etc)

6a. Leg Weakness– Lt 0 = No drift1 = Drifts down does not hit bed6b. Leg Weakness– Rt

(pt holds leg straight out if sitting 300 if s pine)

1 = Drifts down, does not hit bed2 =Drifts down to hit bed3 =Can move but can’t lift

sitting, 300 if supine) 5 sec.

4 = No movementX = 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 paralyzed1 = Clumsy in one limb

shin.) Score only if greater than weakness.

2 = Clumsy in two limbs

SafetySafetyC lC l MiMi ddCommonly Commonly MisMis--scoredscored

8. Sensation (pin prick face, arm, leg –

id )

0 = Normal1 = 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 l9. Language(intubated pt can write. Give blind pt objects to

0 = Normal language1 = Abnormal but understandableGive blind pt objects to

name)understandable2 = Incoherent3 = Mute/Coma3 = Mute/Coma

10 D th i ( l i ) 0 N l ti l ti10. Dysarthria (slurring)(Reads / repeats words)

0 = Normal articulation1 = Slurs but understandableunderstandable2 = Slurs unintelligibly X = Intubated/phys barrierX = Intubated/phys barrier

C lC l MiMi ddCommonly Commonly MisMis--scoredscored

11. Neglect 0 = Normal attention(Ignores one side vision/touch on both sides at once)

1 = Neglects vision or sensation2 ignores one side ofat once) 2 = ignores one side of space; doesn’t recognize arm as own.

SafetySafetyC lC l MiMi ddCommonly Commonly MisMis--scoredscored

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

B d id S ll SB d id S ll SBedside Swallow ScreenBedside Swallow Screen

What the heck RU testingWhat the heck RU testingWhat the heck RU testingWhat the heck RU testingOrOr

h d hh d hWhat does that mean?What does that mean?

1a. Level of Consciousness

0= Alert        1= Sleepy but arousesConsciousness 1= Sleepy but arouses2= 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 tfrontal 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 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 movement1= Partial side‐to‐side eye movement2= No side‐to‐side eye movement

Cranial 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 injury.

If I can’t see – safety risk!

Anterior Cerebral Artery

Middle Cerebral Artery

Posterior Cerebral Artery

Case Study #1Case 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 #1Case 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 #2Case Study #2 26 year old patient comes in with slurred speech (you can

understand her)

Case Study #2Case Study #2

understand 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. 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 #3Case Study #3 71 year old patient comes into the ED with suspected stroke.

Woke up with symptoms Last up to BR at

Case Study #3Case 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 ContinuedCase 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 ContinuedCase 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 #4Case 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 #4Case 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 thatincreased 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 #5Case Study #5 62 year old patient presents with sudden onset of dizziness,

double vision and unsteady gait Also is very nauseated and

Case Study #5Case 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 hehours 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 ContinuedCase Study #5 Continued No facial droop

N k t d t l

Case Study #5 ContinuedCase 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