"untestable" on NIHSS

[kataraang, BSN]

I don't think there's a real debate on this one. NIHSS is standardized for a reason, and there is so much training involved in doing this scale accurately. I'm still a relatively new nurse (1 yr) working in telemetry. I'm only asking because a nurse with many more years of experience than me had documented something that confused me.

On patient with L side paralysis following stroke, I am doing NIHSS. Patient must hold arms out to assess for drift over 10 seconds. On her paralytic side, she has a broken humerus in a sling. I documented as untestable. The CCU had documented as a 4 (no movement). I just think that if there's some reason other than stroke that would prevent testing, then it should be skipped (such as reading words when they don't have their glasses, or an amputee).

Yes I'm nitpicking but I want to get this right. Did I score that item correctly? Thank you!

[kaylee.]

In EPIC there is a link to the explanations for scoring. I open it when I am unsure, or if there are discrepancies. Its pretty straightforward if you use the guide. Otherwise there would be confusion.

https://www.ninds.nih.gov/sites/default/files/NIH_Stroke_Scale.pdf

It looks like for drift no movement = 4, except in joint fusion or amputation. I think the point is they don't want you to be gauging whether its the stroke or the ortho problem. Too many circumstances leads to too much variance and discrepancy.

[Here.I.Stand, BSN, RN]

Was she completely out on the left side -- as in if the ICU RN pinched her fingertip, was she unable to withdraw/no muscle twitch? If that's the case, she has no muscle movement. Nobody is unable to withdraw from pain BUT raise their arms to command.

[cardiacfreak, ADN]

I worked on a telemetry/atroke unit for 18 years. I would have charted no movement only because it is not a joint fusion or amputation. I would have made a comment that stated fracture of L humerus in the comment section.

Just wondering what you charted for ataxia? Not present or untestable?

[PCnurse88]

I asked this exact question when we added NIHSS to our charting, and I was told by neurologists and by the NIHSS educator that this would get a score of 4. We were told the only reason to score "untestable" was amputation or intubated & sedated- BUT I would clarify with your educator and/or stroke coordinator.

[kaylee.]

Ataxia if they are paralyzed (thus unble to demonstrate ataxia) is considered absent.

[mrsboots87]

Also think about this, if you break your humerus, while painful, you should still be able to move your fingers. If you ask the stroke patient to lift their arm to test for drift and they cant even wiggle their fingers in attempt to lift the arm, then it would be considered "no movement".

[kataraang, BSN]

Thank you everyone! A lot more clarity for me now. I will also ask my unit educator. Seems like I should have scored 4.

She had almost no voluntary movement on left (though sensation intact). She at times could wiggle a toe but it wasn't always. Nothing in the arm.

Always learning!