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NIHSS and Aphasia

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by maggdon maggdon, RN (New) New

Right now I am doing the Stroke Scale education and I am wondering about patients who have receptive aphasia. How do you assess these patients for NIH standards? For example, I've had a patient with this and they could perform all the movements/tasks just not when asked. They would do them randomly throughout the day but if you asked they'd just stare at you. How do you recommend following NIH guidelines to score these patients? I've had a neurologist say just watch them throughout the day and see what they can do but some of my fellow nurses disagree. I think if they can do the task the score should be the same as if I had asked them and they completed it. Thought I'd ask the experts 😉

NeuroNerd

Specializes in Neurocritical Care/Neurointerventional Radiology. Has 14 years experience.

I'm sure that you have figured out the answer to this, but just in case you haven' - here you go!  

If the pt can move all extremities, you wouldn't score him for not following commands; you would only score him for his receptive aphasia.  I've had stubborn patients that refused to participate in their neuro assessment when I was in their room, but as soon as I would leave, they would move everything without any issues.  I scored them for what I saw outside the room and documented in the chart that they refused to participate in their exam when I was in the room.  You also have to consider seizure a possibility with 95%, if not all neuro pts.  You always have to watch neuro patients because what they won't do while you're in the room, a lot of the time they'll do when they think you're not watching.  You'll think they cannot move or they have had a neuro change and, next thing you know, they're jumping the side rails standing butt naked ready to go home.  

Assessing neuro patients is an ongoing process.  Not only do you see what they are truly able to do, but you are also able to catch neuro changes quicker and intervene immediately.  I always position myself directly outside my most critical/acute patient to see them throughout my shift.  

nursemike, ASN, RN

Specializes in Rodeo Nursing (Neuro). Has 12 years experience.

On the NIHSS, I would score exactly what happens during the assessment. It's important to be accurate, of course, but the stroke scale is only one tool. A patient who scores 4s on LUE and LLE but changes tv channels with left hand scores 4s with me, but I'll chart what he *can* do on his neuro assessment. I'm not saying I am certain this is best, but it seems consistent with the instructions in the training. After all, their score goes up by one just for being asleep.

I used to be less literal with the GCS. How due you core a patient who is trached with no speaking valve, but writes fluently? These days I give them a one with a comment. I can't tell you how many times I've written "grudgingly" after "follows commands." Q2 neuro checks are my least favorite thing about night shift. 

Most recently, I caught a fellow with pretty severe aphasia having a chat with his aide. Not totally fluent, but much more than I 'd gotten out of him. I mentioned in my note that she was pretty. First case I  can recall of selective aphasia, although I have been accused all my life of selective amnesia.

MunoRN, RN

Specializes in Critical Care. Has 10 years experience.

Anybody asked to perform an NIH stroke scale should be getting the NINDS validated training.  It addresses how to score each item based on issues like receptive aphasia.

One rule that is common for all the questions is that you don't score them for what you think they might be able to do based on separate observations or what you have observed them doing outside of when the scale is administered, otherwise there is no consistency to the scoring which makes the scale fairly worthless, although I would argue it is of little value in clinical decision making even when perfectly done. 

JBMmom, MSN

Specializes in Long term care; med-surg; critical care. Has 9 years experience.

A stroke alert always makes me cringe because it means a post tPA patient will be there for the rest of the shift with the Q15m/30m/1hr neuro checks. Ugh. I always have the nurse handing off to me do a score at the bedside with me so I know how/why they scored as they did. Was there flattening of the nasolabial fold? Is that their normal facial asymmetry? Ugh. And, not everyone scores the same way no matter what. 

I only score based on what I see at the time of assessment. If a patient is not following any of the commands at the time, I will free text that they do not appear unable but the are unwilling to participate in the assessment. I also think it's not a very useful tool in any situations that I have encountered in my three years.