NIHSS stroke scale

  1. 0
    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:

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  2. 27 Comments...

  3. 1
    It depends on your facility. I am in a Neuro Critical Care Unit. We do it on assessment by the stroke team (in ER or on the floor/other ICU), on unit admission and on transfer. This does not preclude us from doing it any other time or PRN. We've had doctors order it daily.

    This is a great training program....
    blueheaven likes this.
  4. 0
    If your institution is following, or working to do so, primary stroke center protocols for the treatment of acute stroke then a scale is required when the patient presents to the facility, 2 hours after tpa (if it is given), 24 hours after the onset of symptoms and at discharge. These are the current reccommendations and part of the tracking that is done to insure quality of care. The NIHSS is not required per se but a scale is. The facility is free to require the scale to be applied at other times it deems appropriate. The NIHSS is really just a standard CN I-CN XII neuro exam that gives a quantitative result that can then be compared for future improvement or decline. For free CEUs and a good class on how to perform the test just visit the American Stroke Association web site.
  5. 1
    I work on an Acute Stroke unit in the UK, we have fairly recently initiated a thrombolysis service, isn't it a trill to see the recovery, resolution of symptoms so rapidly after administration? Sorry - would like to agree within the above our guidelines, we record NIHSS on admission, 2hrs post rtpa - Actiplase - 24hrs then 7 days, not always a discharge date, often our patient move on to rehabilitation from our unit. Again what a thrill to see the inprovement and discharge home so quickly after major brain injury could have been sustained
    Beentheredonethat likes this.
  6. 2
    Nice to hear from other Neuro nurses. Where in the UK. I also do air ambulance and repatriated a man back to London in December. Sorry, I don't remember the name of the hospital. It was near the airport but it wasn't Healthrow. Our NIHS use is based on the American Stroke Assoc. 7 days would easily place most out of hospital here so a DC time is still close to yours. I work as a coordinator for all strokes in a 1,000 bed facility. Respond to in house strokes and the ER during the day shift. Do you have established clinical care pathways? We have dedicated orders but are gearing up for clinical pathways. Yes, it is nice to see a recovery before your eyes. take care.
    MaxtimeNP and santonyxx like this.
  7. 0
    We use it on a daily basis............and it sucks. Its a very good scale, is time consuming when you have multiple things going on in the unit. It is mandatory on all of our carotids as well as some other patients and types of surgeries.
  8. 0
    Must agree its very time consuming and ardouos at times, however sensitive enough to detect Stroke specific deterioration. Does anyone use any kind of abridged version that could be used more routinely as regular observations, such as the GCS (Glasgow Coma Scale) is used?
  9. 1
    The NIHSS is a good scale but nurses don't like it. I personally think it is because they don't really understand a neuro exam and since this is a neuro exam bam they don't like it. Once you have it down pat it isn't any more difficult than shooting pressures and figuring out what is wrong with a CABG.

    With that said. I introduced a neuro exam that, sorry the pun, is a no brainer. The nurses who were complaining about the NIHSS love it and want to trial it as their standard exam and to use at change of shift.

    The MEND exam is the Miami Emergency Neruo Diagnostic exam that EMS is being taught to use in the field to more accurately diagnose and report on stroke pts. I just taught it to our new Rapid Response Team and they wanted more. You can goodle MEND and get most of the info on it or contact the University of Miami, Fl for official classes.

    Funny part is that it is rather like the NIHSS only I taught it as a exam that you can use with present skills and therefor not have to learn neuro. The mind fake out worked. After a while people will figure out that they can do the NIHSS once they get over the fear factor, but until then they are using a tool that is appropriate instead of the GCS. Stroke is not a head injury and should not be validated with a head injury tool.

    As mikey used to say "try it you'l like it."
    santonyxx likes this.
  10. 0
    Hello, I am also a stroke coordinator in NYC. I am searching for a one page NIHSS, to be used in our units instead of the current two page document. Do you happen to have one?
  11. 0
    We use the complete set. We did work on so that it is a tri-fold with the directions/scoring on one side and the pictures/words/scentences on the other.

    There is an older model that has fewer instructions and a more streamlined scoring that is a one pager. I will check tomorrow and see if we still have it electronically. If so I will be happy to email it to you. Otherwise I have it as hardcopy somewhere and can mail it to you.

    We changed to the more expanded version (read that as extensive directions) to help guide the nurses through it. Found that our staff really needed the extra pointers to help them through it and increase compliance.

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