National Institutes of Health Stroke Scale Workshop ...

National Institutes of Health Stroke Scale Workshop Evaluation Options

There are many evaluation options included in the introduction of the NIHSS into practice. The first two relate to clinical competency in performing and scoring the NIHSS. The last three refer to system and program evaluation. Evaluation tools are provided for Options 1 & 2. Evaluation Tools for Options 3, 4,& 5 should be developed to meet the organization’s needs and goals.

Option 1: Self-Assessment (Knowledge and Skills)

Using Self-Assessed Competency of Neurological Assessment Techniques particular to the NIHSS form (see page 3). This self assessment is designed to be completed at the following points:

Pre-NIHSS education session

6 months post-NIHSS education to identify learning needs

Option 2: Clinical Performance Competency

The workshop is designed to provide the participant with knowledge and skills required to confidently use the NIHSS in the clinical setting.

Competency is obtained through practice and interaction with the trainers/resource people in the clinical setting.

Evaluation of competency in performing and scoring the NIHSS is done at the bedside using the Bedside Evaluation for Clinical Competency form (see page 9).

Option 3: Evaluation of the Implementation Process

Designated focus group sessions or one on one discussion with manager and/or educator can be used for this evaluation component. Some topics to cover at this time can include:

Satisfaction, practice issues, and challenges.

Perceived impact of the NIHSS on communication between nursing colleagues, physicians and patients/families.

Perception of consistency, reliability and validity in the use of the NIHSS.

Perception on the effect of the NIHSS on quality of care for patients.

Option 4: Evaluation of Compliance

Chart audits assessing compliance, documented communication of neurological decline, documentation of associated interventions and follow-up can be completed at 6-9 months after implementing the NIHSS in practice.

Option 5: Evaluation of Sustainability

Based on the evaluation components chosen, a formal review by team members of all information gathered is important to identify issues for ensuring a sustainability plan.

NIHSS Evaluation Options, 2008 2

Option 1: Self-Assessed Competency of Neurological Assessment Techniques

It is recognized that each person engaging in these education sessions comes with a foundation of knowledge and skills acquired from experience. The purpose of these education sessions is to build on current abilities, facilitate professional development and performance enhancement, and provide updated information regarding current best practices.

To facilitate an understanding of your strengths and areas for skill development, we ask you to complete the Self Assessed Competency of Neurological Assessment Techniques. It is advisable to repeat this assessment in 6 months to identify ongoing learning needs and the impact of the education that was received earlier.


Self-Assessed Competency of Neurological Assessment Techniques

Circle one of the following:

Pre-NIHSS Education QuestionnaireOR6 months Post-NIHSS Education Questionnaire

Name:

Years working:

Categories Used in This Self-Assessment

Use the following levels to determine your level of skill and knowledge in performing the competencies identified.

LEVEL SKILL & KNOWLEDGE

EXPERTAnalysis, synthesis, application, *highly skilled performance

Extensive exposure, with deep understanding of situation Able to rapidly and consistently identify actual and potential assessment changes

Able to rapidly change priorities under all conditions

Able to keep personal values in perspective and therefore able to encourage and support patient and family choices

PROFICIENTConceptual understanding, *proficient performance

Extensive exposure in most situations Able to anticipate potential assessment changes


LEVEL SKILL & KNOWLEDGE Able to prioritize in response to changing situations

Able to interpret the patient and family experience from a wider perspective and can envision possibilities

COMPETENTConceptual understanding and skill performance *competent

Varied exposure to many situations Able to identify normal and abnormal findings

Able to prioritize under stable conditions

Increased awareness of patient and family viewpoints

ADVANCED BEGINNER

Conceptual understanding, minimal clinical experience

Limited exposure to clinical situations Able to identify normal findings

Guided by what they need to do, rather than patient responses

NOVICE Marginal conceptual understanding, minimal clinical experience

Seeks assistance in making clinical decisions


Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley

LEVEL SKILL & KNOWLEDGE Stages of Competency

E= Expert

P= Proficient

C= Competent

AB= Advanced Beginner

N=Novice

E P C AB N

CLINICAL SKILLS, CRITICAL THINKING AND PROFESSIONAL BEHAVIOUR

1. I use a variety of neurological assessment techniques to collect data pertinent to my patients.

(a) I am able to accurately determine the patients’ level of consciousness.

(b) I incorporate neurological examination techniques to complete a comprehensive assessment when assessing stuporous or comatose patients.

(c) I am able to accurately assess the mental status of my patients including the patient’s orientation, awareness, attention and concentration level, comprehension, memory, reasoning and judgment.

(d) I have the skills and knowledge to assess the patients’ gaze and extraocular movements. I can determine a normal and abnormal response.

(e) I am competent in the assessment of gross visual fields. I have the skills and knowledge to determine a normal and abnormal response and identify hemianopias.



(f) I am able to accurately assess facial palsy. I incorporate testing into my assessment to determine if the patient has motor weakness of the lower face only or both the upper and lower face.

(g) I am competent in the assessment of motor strength and drift. I utilize various assessment techniques to determine subtle weakness and changes in the patients’ motor strength.

(h) I am able to accurately assess limb ataxia. I use assessment strategies to determine cerebellar impairment. I assess limb movement abnormalities in relation to sensory or motor dysfunction.

(i) I am competent in the assessment of sensation. I utilize light touch as well as sharp/dull testing assessment techniques when appropriate based on the patients diagnosis and situation.

(j) I am competent in the assessment of expressive and receptive communication deficits. I am able to perform a general assessment to determine the patients’ ability to understand the spoken and written word and to express thoughts orally and in writing.

(k) I am competent in the assessment of dysarthria. I evaluate the patients’ clarity of speech.

(l) I have the skills and knowledge to assess the presence or absence of “neglect”. I assess inattention to aspects of the patients’ senses including visual and tactile stimuli. I use assessment techniques to determine if a patient is not aware of (or is unable to identify) physical deficits.


LEVEL SKILL & KNOWLEDGE Stages of Competency

E= Expert

P= Proficient

C= Competent

AB= Advanced Beginner

N=Novice

E P C AB N

CLINICAL SKILLS, CRITICAL THINKING AND PROFESSIONAL BEHAVIOUR

2. I use a variety of assessment techniques and information sources to collect data pertinent to my neuroscience patients.

(a) I determine the right data collection method based on my patient’s condition (e.g. interviewing, listening, consulting, auscultating, percussing, observing, palpating, inspecting, monitoring, measuring)

(b) I use identified patterns/trends to direct further assessment needs and synthesize all data to make care decisions

(c) I identify potential and actual situations of patient risk based on assessment results and take action to ensure patient safety

(d) I communicate changes in patient condition and document situations and outcomes to the appropriate authority in an objective and timely manner



3. I identify and prioritize nursing interventions.

(a) I create a plan of care in collaboration with the patient and other team members that is based on patient priorities

(b) I develop a written plan of care

(c) I identify interventions and modify the plan of care based on actual or potential problems

4. I exercise professional judgment in decision-making.

(a) I assess the risks and benefits of the required actions based on my patient’s condition, determine the actions to be performed and can provide a rationale for my decisions

(b) I consult with others when I reach the limits of my knowledge and skill

5. I use problem-solving skills when responding to critical and ongoing situations.

(a) I identify problems based on my patient’s condition and determine if the problem is within my scope of practice

(b) I decide appropriate actions considering possible risks and benefits and collaborate with appropriate health care providers as necessary


Option 2: NIHSS Bedside Evaluation for Clinical Competency

Circle yes/no as appropriate. Shaded areas to aid evaluator

Identifies frequency of full assessment: YES NO

1) TID during the first 72 hours after admission for stroke (or as per institutions guidelines)

2) With any decline in neurological status

3) When the patient is received from ER, ICU, or PACU onto unit Name: _____________________

4) After the 72 hour period - with any changes in neurological status Date: ______________________

CATEGORY Description

S

c

o

r

e

Correctly identifies the following:

1a. Level of consciousness

***(Patients who score 2 or 3 on this item, should be assessed using the Glasgow Coma Scale)

Alert

Not alert

Not alert

Totally unresponsive

0

1

2

3

Pt keenly responsive

Pt requires minor stimulation to obey, answer, or respond

Pt requires repeated or painful stimulation

Pt totally unresponsive (except reflexive effects)

Identifies correct score: YES NO

If pt scores 2 or 3, “Do you continue with this examination or refer to the GCS instead?” Participant identifies the GCS is used INSTEAD of the NIHSS: YES NO


**Bedside NIHSS evaluation deferred for another pt.

If pt scores 0 or 1, “Do you still complete the GCS as well as this document?” Participant identifies the GCS is NOT completed YES NO

1b. LOC, questions

(month, age)

Answers both questions correctly

Answers one question correctly

Answers neither question correctly

0

1

2

Correct response ONLY includes correct Month, Age YES NO

“If the pt states their date of birth, corrects themselves, or comes close can you count this as a correct response?”

The participant verbalizes such responses are incorrect: YES NO

“If pt correctly identifies the year, their date of birth, or the place, does this affect their score on this item?”

Participant verbalizes the score for this item is based ONLY on month and age, not other questions such as year, date or place: YES NO

1c. LOC, commands

(Open/close eyes, make fist,

release fist) Pantomime may be used

Performs both tasks correctly

Performs one task correctly

Performs neither task correctly

0

1

2

Identifies correct score: YES NO

“Can you use pantomime in a pt that does not follow commands?”

Participant verbalizes pantomime can be used on this item: YES NO

“Can you substitute a different one-step command in a pt that is unable to use their hands?” YES NO “Give an example of a one step command you could use.”

Participant verbalizes a one step command. YES NO 2. Best gaze

(Patient follows examiner’s finger or face through full horizontal field)

Normal

Partial gaze palsy

Forced deviation (not overcome by oculocephalic maneuver)

0

1

2

Assesses horizontal gaze (+/- other ocular movements): YES NO

Correct score identified (only scores pt as 1/2 if deficits are clearly present: YES NO

If unable to follow commands (confused, aphasic) uses tracking techniques to assess gaze: YES NO

“Describe how you would assess a pt using “tracking”:

Participant able to identify technique for tracking (moving face in front of pt and/ or moving about the room): YES NO

“Describe the oculocephalic technique. What would you see in a normal and abnormal response? Able to identify technique for oculocephalic maneuver and is able to state the normal response (eyes move opposite to direction head is turned) and abnormal response


(eyes remain fixed in one position when head is turned): YES NO3. Visual

(Introduce visual stimulus/threat to patient’s field quadrants)

No visual loss

Partial hemianopia

Complete hemianopia

Bilateral hemianopia

0

1

2

3

Tests each eye independently and tests all 4 quadrants of each eye: YES NO

Correctly performs visual testing (asks pt to look directly into his/her eyes, asks pt to cover one eye, introduces visual stimulus into each quadrant – visual threat used PRN): YES NO

“How do you assess an aphasic pt for visual loss?”

Participant identifies how to perform visual threat in a pt unable to follow usual visual testing: YES NO

Please fill in the circles to demonstrate the following deficits:

Partial hemianopia

Complete hemianopia correctly identifies these:

YES NO

Bilateral hemianopia


4. Facial palsy

(Show teeth, raise eyebrows,

squeeze eyes shut) Pantomime may be used

Normal

Minor paralysis

Partial paralysis

Complete

0

1

2

3

Normal

Mild asymmetry on smiling (flattened nasolabial fold, fewer teeth on one side with smile)

Paralysis of lower face

Paralysis of upper and lower face (one or both sides)

identifies correct score: YES NO

“What is a flattened nasolabial fold?”

Participant identifies characteristics of a flattened nasolabial fold: YES NO

“Would you use pantomime in an aphasic patient who does not follow commands?” verbalizes he/she would use pantomime with such a pt: YES NO

“Could you use a cotton applicator tip to tickle each nasal passage of an aphasic or lethargic pt to compliment your assessment of facial palsy?”

Participant verbalizes he/she can tickle each nasal passage to determining a valid response: YES NO

5a. Motor arm - Left

(Test each limb independently: Palm Down: Elevate arm to 90 if pt sitting, 45 if pt supine and score drift/movement over 10 seconds)

No drift

Drift (drifts but does not fall to rest on a support)

Some effort against gravity (drifts to fall on support)

No effort against gravity (trace movement, limb falls immediately)

No voluntary movement

Amputation, joint fusion etc

0

1

2

3

4

X

Correctly scores R arm: YES NO

Correctly scores L arm: YES NO

Asks patient to hold their hands in a “Palm Down” position: YES NO

Counts out loud for a full 10 seconds (or until arm hits support): YES NO

Tests each arm independently: YES NO

Places pt’s arms at 90 if pt sitting, 45 if pt supine: YES NO

“If the pt does not follow commands, what could you do to encourage them?”

Participant verbalizes he/she can position the pt’s arms at 90, use pantomime and use urgency in his/her voice.: YES NO

5b. Motor arm – Right


6a. Motor leg – Left

(Test each limb independently: With pt supine, elevate extremity to 30 and score drift/movement over 5 seconds)

No drift

Drift (drifts but does not fall to rest on a support)

Some effort against gravity (drifts to fall on support)

No effort against gravity (trace movement, limb falls immediately)

No voluntary movement

Amputation, joint fusion etc

0

1

2

3

4

X

Correctly scores R leg: YES NO

Correctly scores L leg: YES NO

Tests each leg independently: YES NO

Counts out loud for a full 5 seconds (or until leg hits support): YES NO

Places pt’s in supine position and elevates leg to 30: YES NO

“If the pt does not follow commands, what could you do to encourage them?”

Participant verbalizes he/she can position the pt’s leg at 30, use pantomime and use urgency in his/her voice: YES NO

6b. Motor leg - Right

7. Limb ataxia

(Finger-nose, heel down shin)

Absent

Present in one limb

Present in two limbs

0

1

2

Correctly performs “finger-nose” testing: YES NO

Correctly performs “heel down shin” testing: YES NO

Only scores ataxia as being present if it is clearly demonstrated: YES NO

“In a patient with severe weakness or aphasia who is unable to follow directions, what score would you give them on this item?” Ataxia is scored as 0 (absent) by the (because it can not be clearly demonstrated that it is present): YES NO

8. Sensory

(Pin prick to face, arm, trunk, and leg – compare side to side) Look at grimace in aphasic patient

Normal

Mild to moderate sensory loss (less sharp/dullness)

Severe or total sensory loss (not aware of touch)

0

1

2

Correctly scores sensory exam: YES NO

Uses a safety pin to test sensation: YES NO

Does not test sensation on hands or feet (rather uses arms and legs related to the incidence of neuropathies in hands/feet): YES NO

Only scores the sensation as a 1 or 2 when it can be clearly demonstrated: YES NO

“If the patient had sensory deficits not related to the current stroke such as diabetic neuropathy or other pre-existing conditions would you score only their stroke related sensory loss, or also their sensory loss related to these conditions?”

Participant verbalizes that ONLY sensory deficits related to stroke are scored: YES NO9. Best language No aphasia 0 Correctly scores best language: YES NO


(Name item, describe a picture and read sentences)

Mild to moderate aphasia (reduced fluency or comprehension)

Severe aphasia (communication exchange very limited)

Mute, global aphasia

1

2

3

Asks pt to read all sentences and name all items: YES NO

“Would you encourage a non-verbal pt to write their responses?”

Participant verbalizes patients who cannot verbalize may write their responses: YES NO

“If a patient follows simple one-step commands, but does not express themselves using speech, would you score them as a 2 or a 3?”

Participant verbalizes the patient would receive a score of 2, because they exhibit some auditory comprehension: YES NO

“If the pt does not describe a portion of the picture, how would this affect your assessment of extinction/inattention?”

Participant identifies double visual stimulation should be tested: YES NO10. Dysarthria

(Evaluate speech clarity by having patient read or repeat listed words)

Normal articulation

Mild to moderate dysarthria (can be understood)

Severe dysarthria (unintelligible or worse)

Intubated or other physical barrier

0

1

2

X

Correctly scores dysarthria: YES NO

Asks pt to read word list: YES NO

“If the pt were unable to read from the listed words, would you ask them to repeat after you?”

Participant verbalizes they would ask the pt to repeat after him/her: YES NO

11. Extinction and Inattention

(Use information from prior testing to identify neglect or double simultaneous stimuli testing)

No abnormality (no neglect)

Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral stimulation in one of the sensory modalities)

Profound: more than one modality affected

0

1

2

Correctly scores extinction and inattention: YES NO

Performs double simultaneous testing of vision (L, R, both – tests upper and lower visual fields) and tactile senses (with pts eyes closed asks “Which side am I touching? L, R, or both?” – tests face, arms, legs): YES NO

“What is the difference between a score of 1 and 2?”

Participant verbalizes an understanding of the difference between a score of 1 (inattention to one sensory modality) and a score of 2 (inattention to more than one sensory modality):


YES NO

“What score would you give to a patient who does not recognize their own hand as part of their body?”

Participant verbalizes a score of 2 because the pt shows both tactile and personal inattention. YES NO

TOTAL SCORE

Calculates a total score: YES NO

Records only actual patient response (not what he/she thinks the pt can do): YES NO

Only uses coaching/pantomime for 1b LOC commands, 4. Facial or 5. & 6. Motor Arm/Leg: YES NO


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