Jump to content

NIHSS stroke scale

Posted
by ferde1 ferde1 (New) New

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:

RoxanRN

Specializes in CCRN, CNRN, Flight Nurse. Has 10 years experience.

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.... http://asa.trainingcampus.net/uas/modules/trees/windex.aspx

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.

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 :yeah:

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.

joeyzstj, LPN

Specializes in CVICU, ICU, RRT, CVPACU.

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.

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?

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."

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?

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.

sleepyrasrn

Specializes in Neuro ICU, Cardiothoracic ICU.

I work in a trauma 1 neurosurgical ICU and we use the NIHSS on any patient suspected of having a new stroke. We have a stroke team that I run on and the NIHSS seems to be a fantastic way to quantify patient symptoms and a good way to give the family reasonable expectations of what the patients outcome will likely be.

We don't use the scale for normal assessment of neuro patients. Our assessment includes assessment of GCS, mental status/cognitive questions, cranial nerves assessment, and assessment for upper and lower extremity drift. We do this Q1 or Q2 hrs based on acuity.

It is really great to see so much interest in assessment of neuro pts. A neuro assessment is vital signs for the brain. As many are reporting, it can be done and with great accuracy/results. Stroke teams deserve all the credit they can get.

Any one out there trying to start up stroke centers or stroke teams jump in with questions/answers. This is a great place to share the wealth.

misswoosie

Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH. Has 26 years experience.

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.

Link to our multidisciplinary stroke pathway and thrombolysis protocol here.

Anyone in the UK using ROSIER as a triage diagnostic tool in the emergency department ?

http://www.northumbria.nhs.uk/menu.asp?id=258565

Misswoosie:

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. :loveya:

ghillbert, MSN, NP

Specializes in CTICU. Has 25 years experience.

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.

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!:specs:

misswoosie

Specializes in ICU,ANTICOAG,ACUTE STROKE,EDU,RESEARCH. Has 26 years experience.

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.

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 :banghead: is to ask them to perform a neuro exam. Thanks again for your info and support.:up:

Guest
This topic is now closed to further replies.