Use NIH Stroke Scale to assess patients
There is a valuable tool for assessment of stroke and transient ischemic attack (TIA) patients you might not be using in your ED, warns Susan Unipan Rodriguez, BSN, CNRN, nurse coordinator for the National Institutes of Health/National Institute for Neurological Disorder and Stroke (NINDS), Stroke Branch/Stroke Diagnostics and Therapeutics, based in Bethesda, MD.
Using the National Institutes of Health (NIH) Stroke Scale takes approximately seven minutes to perform and should be standard practice for all patients with suspected TIA or stroke, says Rodriguez. (See stroke scale, guidelines, and learning packet, inserted in this issue.)
The 42-point scale can quantify most stroke symptoms. It gives you an idea of whether the stroke is mild, moderate, or severe, with 0 being normal and 42 most severe, says Rodriguez. "It’s a great tool to utilize, and gives you a thorough neurological exam on these patients."
Neurologic status addressed
The Glasgow Coma Scale is usually the only tool used in the ED to assess neurological symptoms, but that scale doesn’t tell you anything about a stroke patient, Rodriguez says. "The NIH Stroke Scale tests level of consciousness in a different way than the Glasgow Coma Scale, such as the following of commands. It gives you a thorough idea of the patient’s neurological status."
The NIH Stroke Scale quantifies visual and speech disturbances, severity and location of weakness, and neglect, all of which are not usually measured in the ED, says Rodriguez. "These are symptoms that really impact how these patients do over the long term, which might not be picked up initially."
The stroke scale is an excellent predictor of patient outcomes, stresses Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the Department of Emergency Medicine at University Hospital, University of Cincinnati Medical Center and consultant for the National Stroke Association, based in Englewood, CO.
The stroke scale score is an effective way to predict what will happen to stroke patients, Spilker says. "When a patient comes to the ED, we know at the baseline what their likelihood of getting better is," she says. "It also allows you to tell if the patient is getting better or worse."
Looking at the big picture
Documentation of a patient’s neurological deficits is currently performed differently by each specialty and department, and the stroke scale can provide consistency, Spilker advises. "You want to look at the big picture of disease management from the ED until the time of discharge from the hospital, and this standardizes the assessment," she says.
Health care for stroke patients is compartmentalized between the ED, hospital, and rehabilitation, notes Spilker. "In order to connect all these three, we have to have this in common."
There are 11 items to complete, and the scale is lengthy, Spilker acknowledges. "But the more proficient you become, the faster it is to administer," she says. If you partner with more experienced people, it will be easier, Spilker advises.
Using the NIH scale should be part of your standard assessment of stroke patients, Spilker argues. "Before we had treatments for stroke, there wasn’t much incentive to doing this. But there is enough ammunition now to justify this change."
The rationale is growing stronger for ED nurses to do this assessment, Spilker stresses. "You need to accept that performing a full awake neurological exam is part of your job."
The scale must be fully completed, Spilker recommends. "If you only do one or two items, you are not getting a complete picture," she says. "Making it shorter is like doing two or three leads out of a 12-lead EKG."
Stroke scale scores can help you decide which patients should be treated with thrombolysis, says Spilker. "There are always exceptions, but generally speaking, small scores do well, and big scores do poorly," she explains. "As the number gets higher, your risk of hemorrhage increases."
For more information about the National Institutes of Health Stroke Scale, contact:
• Susan Unipan Rodriguez, BSN, CNRN, National Institutes of Health/NINDS, Stroke Branch — Stroke Diagnostics and Therapeutics, 10 Center Drive, Building 10, Room 3B10, Bethesda, MD 20892. Telephone: (301) 402-7365. E-mail: [email protected].
• Judith Ann Spilker, RN, Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Bethesda Ave., Cincinnati, OH 45267-0769. Telephone: (513) 558-8106. Fax: (513) 558-6299. E-mail: spilkeja@ ucmail.uc.edu.
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