NIHSS stroke scale - page 2

I am told we will be using the NIHSS stroke scale in our SICU and that we only need to do it on assessment , after 48 hours and then again at transfer. Is this standard practice?:uhoh21:... Read More

  1. by   Beentheredonethat

    Thank you for taking the time to respond to my request and a big hug and kiss for all the information! I have spent several hours reviewing the information and have to say I am envious. You guys have this down to a very simple but comprehensive application. I am going to incorporate many of the presentations for our program. Hopefully, this will help our staff to overcome their resistance and give them the knowledge to improve their practice.
  2. by   ghillbert
    I don't understand how people think it's time consuming and/or "arduous" - it takes less than 10 minutes and is both diagnostically and prognostically important. The more often you do it, the quicker you get.
  3. by   Beentheredonethat
    Your institution can establish their own "standard of practice". In the case of acute stroke we use it in two different time tables.

    If the pt received tpa we use it during the emergency workup, two hours post tpa, 24 post onset of symptoms and at discharge.

    If the pt did not receive tpa we use it during the emergency workup, 24 post onset of symptoms and at DC.

    I think I hear a little concern in your voice. Relax, the NIHSS is just a neuro exam that gives a number. Using it will insure a complete exam of your pt and help to refine your assessment skills. There are plenty of on line education formats to help you to learn how to use it. Just google NIHSS. We actually pay our staff for 4 hours of eduation when they become certified in NIHSS. If you are treating acute stroke pts, staff who assess during the tpa workup must be certified. Happy learning!
  4. by   misswoosie
    Thanks Beentheredonethat-you are very welcome.
    I am not even sure if ROSIER (Recognition Of Stroke in ER) has been added to our protocol yet.It is an excellent tool which was developed for use by Doctors in ER, but is now being validated for use by paramedics. It is a step up from FAST, and aims to predict the likelyhood of stroke being the cause of the neurological deficit.
    So presence of certain things are scored positively,whilst others are scored negatively.

    As for NIHSS it was first developed purely for thrombolysis patients, and they are the only patients we use it for. Initially I used it for thrombolysis clinical trials 10 years ago and it does require certification every 2 years.
    There is actually a move away from using the NIHSS in thrombolysis, purely because it is not an easy scale to use and requires some practice.
    A patient can have an NIHHSS of 0 and still have had a stroke, so it is not a substitute for a full neuro exam to assess the type of stroke a patient has had ie the Bamford classification of stroke ie LACI,PACI,POCI or TACI.
    It is the BAMFORD classification (plus CT evidence etc) which people use to quote mortality/recovery rates , either with or without thrombolysis treatment.
    With experience you can tell very quickly using FAST and a few other quick tests what type of stroke they have had.
  5. by   Beentheredonethat
    I reviewed the ROSIER info you sent. It is similar to a screen that is now being taught to our EMS folks and I recently introduced to our ER and rapid response team. Called the MEND exam. Short for Miami Emergency Neurologic Diagnostic. It is also a yes/no format that is fast, simple to use and a good indicator of stroke and stroke snydrome. Our equivalent of your Bamford classification. Our staff is not as sophisticated so trying to wean them away from an alert and oriented, moves all extemities assessment meant we needed a common format for them to adhere to. For now we are using the NIHSS until they build their skill set and can move forward. I really was envious of the baseline level of care that your system has. In many areas in the US we are still fighting the old attitude of nothing can be done for stroke and bare bones neuro exams. The fastest way to clear a room of nurses here is to ask them to perform a neuro exam. Thanks again for your info and support.
  6. by   misswoosie
    The level of care stroke patients receive varies depending on the comittment of the Stroke physicians in any hospital, or it did until the Department of health brought the National Stroke strategy earlier this year.
    Now everyone has to have access to a stroke thrombolysis service, whether that be at a regional center or their local hospital. Bit difficult to have a regional service when we are in a fairly rural area with no air ambulances with the 3 hr timescale-of course the results of ECASS III released 2 weeks ago showed it was beneficial up to 4.5 HOURS.

    I have heard of MENDS -if you don't mind telling me -what is your job title and which state do you work in? You can PM me if you want
  7. by   gwapo
    hello. it's my fist posting in this thread. i work in an MSICU somewhere in southwest florida and recently, they have decided to have us do NIHSS on every neuro patient. Does this make sense? As I understand it, NIHSS is used for stroke patients to provide a baseline assessment prior to treatment (tpa or whatever) and evaluate effectiveness of it. I know all stroke patients are neuro patients, but not all neuro patients are actually stroke. So why do NIHSS on all neuro patients??? Any input will be appreciated. thank you.
  8. by   misswoosie
    Excuse me as I am in the UK-but what is MSICU?
    The NIHSS (National Institute for Health STROKE Scale) was as you say developed for Stroke patients.
    I guess you could use it on head injury patients to assess neurological deficit, maybe???
    What other type of patients do you care for?
    If they are doing it at admission to screen for stroke then it's not really appropriate and a Stroke screening tools ie ROSIER,MENDS,FAST would be better.

    Hope this helps!
  9. by   gwapo
    Quote from misswoosie
    Excuse me as I am in the UK-but what is MSICU?
    The NIHSS (National Institute for Health STROKE Scale) was as you say developed for Stroke patients.
    I guess you could use it on head injury patients to assess neurological deficit, maybe???
    What other type of patients do you care for?
    If they are doing it at admission to screen for stroke then it's not really appropriate and a Stroke screening tools ie ROSIER,MENDS,FAST would be better.

    Hope this helps!
    MSICU= med/surg icu. last weekend i had a patient who came from OR post craniotomy for suspected glioblastoma.usually, we won't do an NIHSS on her, but since they want us to have it done on all patients, we did it anyway. does it make sense?
  10. by   Beentheredonethat
    This is a good question and one that was asked by our staff after we instituted the same policy. First, you are right that the NIHS is used for stroke. What we found is that there has been resistance to using the NIHS and often the folks who resisted did not have the best neuro assessment skills. Neuro exams without a scale have often been subject to a wide range of subjective rather than objective interpretation and difficult for one person's assessment to be validated by anothers. In short, it helped to standardize everyones exam.

    It isn't perfect, but there aren't too many scales out there and it is the most used so it acility and another. Once you have it under your belt it won't take any time at all to perform.
  11. by   Beentheredonethat
    Sorry, the key board died so the rest of the message did not make it. I was going to say that it provides a common language between shift, departments and other facilities.
  12. by   misswoosie
    I think it would be beneficial to have stroke as a separate speciality on the all nurses forum.
    I am sure that not all stroke patients in USA are cared for on ICU, and certainly here in England although we have regional neuro ICU s, they are generally for neuro trauma/surgery patients and run by neurosurgeons, so very few stroke patients make it there.Even "general" ICUs which is all most county hospitals have are very reluctant to take stoke patients, unless they had the stroke post surgery or have also had an MI!
    Our stroke patients are cared for on a stroke unit which started off as a ward for elderly medical patients, so you can imagine it is a difficult transition for staff. That is why we only have the Stroke NP,Stroke physicians and research nurses doing NIHSS.
    We have developed another obs chart for use on high risk stroke patients and for for post thrombolysis. It is a 24 hour chart which evaluates conscious level, speech and limb power on a quantified scale.It also has BP,pulse.O2 Sats,temp on it and has instructions on how to respond if changes meet particular criteria.
    Some "stroke" units may have one 6 bedded bay (we only have 2-3 private rooms on a ward and usually they are for infectious patients of those that are dying) for hyperacute stroke patients and offer continuous monitoring, but we don't have that yet.
    We also have the rehab patients on the same ward!
    What I am trying to say is that stroke is high priority in most developed countries and deserves to be a speciality in its own right here.
  13. by   Beentheredonethat
    With the advent of Primary and Comprehensive stroke centers starting to come into play and the evolution of a national standard such as Get With the Guidelines stroke is on the doorstep of being a subspecialty. It has had more time to evolve into a specialty for our physicians (USA) but has not made that transition for nursing.

    I couldn't agree more with a dedicated stroke forum. It would provide fast and more efficient searching for answers and sharing of the wealth. OK that may sound like a presidential political statement so I will clarify, the wealth of knowledge.

    By helping, supporting and sharing with each other we not only provide nuturing for the few who go into this field but improve the standards of care for our patients.

    Lets do it!