The National Institute Stroke Scale - Research Paper Example

The National Institute Stroke Scale Clinical Topic of Interest - Stroke Stroke case: A 33 year old female was admitted to hospital due to moderately severe headache with ictus for a week. After that she felt weakness in the right side limbs which is caused by dysphasia. This unmarried young woman with normal health till this ictus had no family background of stroke syndrome. Her physical condition was normal with normal blood pressure and she was non diabetic. She was not affected by any cardiac problems. Such cases are increasingly reported in United States and thus need for technologies related to stroke treatment is increasingly felt in the current social situations. Stroke statistics: Stroke is the third largest killer disease in USA. In 2005 it was recorded that about 143579 people were killed by stroke. Stroke causes serious long term disability on a large scale in the country. It is estimated that there are about 6500000 people as stroke survivors and among these 26lacs are male and 39lacs are female. As per the studies of GCNKSS/NINDS, about 795000 new cases of stroke are reported annually. Among these new cases, six lacs are first attacks and 180000 are repeat attacks. The statistics in 2005 for stroke deaths show that females account for about 60.6 % of the stroke deaths. When taking the annual stroke data from 1995 to 2005, there is a declining trend and it is about 29.7%. The actual number of stroke deaths is also reduced to a rate of 13.5%. (Stroke Statistics, 2009). NIHSS: The National Institute of Stroke Scale can be applied in several situations relating to stroke. The major purpose of the scale is as a clinical medicine. It is used for assessing the degree of disability caused by stroke treatment using tPA. The second major application of the scale is in research field. In research field it can be used for the objective comparison of efficiency of different stroke treatment and rehabilitation involvements. The NIH scales quantify the different aspects of brain functions such as consciousness, vision, sensation, movement, speech, and language. Specific number of points is attributed to the impairment of these separate functions that are uncovered during the neurological examination. The score of 42 is the maximum and it implies a most severe and overwhelming stroke. AS per the new guidelines, a score with more than 4 points have to be treated with tPA. The level of stroke severity under the NIH Scale scoring is described below: “ 0= no stroke 1-4= minor stroke 5-15= moderate stroke 15-20= moderate/severe stroke 21-42= severe stroke.” (Vega, 2009). : Literature of science of the topic: The NIHSS is an effective tool for identifying the severity of strokes. The neurologic terminology used in this scale causes problems for nurses. Thus a modification is needed in the scale related to the language. So the neurological terminology in the scale is replaced by plain English. This replacement makes the scale more comfortable for the nurses. The NIHSS was originally framed as a research tool for testing the severity of various types of strokes. Over the years it has been developed as a significant standard for assessing and measuring the stroke. In the present era this scale is generally considered as a tool for determining the treatment options on various kinds of stroke incidents. It can be effectively used for foreseeing the discharge planning and testing the patient outcomes. Specialized training is needed for using this scale measure. The users have to be well acquainted with the specialized Neurology terminology in the scale for identifying its accurate measurement. For providing training to the nurses online courses are offered by the American Stroke Association. It involves average 2 to 3 hours training for each of the trainees. The Scale facilitates the measurement of stroke at the initial stage and verification of its severity. Thus the controlling of the alteration in the patient’s condition is possible through this tool. In this tool, the stroke severity is measured in numerical terms. By comparing the recorded scores in different time periods, it is possible to find out the improvement in the patients’ condition. For the caregivers this tool is helpful for collecting the data regarding the severe stroke syndrome in different groups of individuals. “The American Hearts Association, Get with the Guidelines collects data on indictors of quality stroke care including whether the initial NIHSS was done on each stroke patient.” (Dancer, Sandy, Brown, Allen, Yanase, & Rietz, 2009). Providence Portland Medical Centre is a prominent medical service centre in Portland. It has bed facilities of 483 patients. Providence Health System is the group in charge of the hospital. In the PPMC, an average of 400 stroke patients gets admitted annually. It is a nationally recognized centre for high quality stroke treatment. The American Stroke Association has approved it as a centre of excellence in the treatment of stroke and certified it as the Primary Stroke Centre. It exceeds the national benchmarks in following the guidelines of the ASA. With regard to the excellent performance in the field of stroke treatment it received the Gold Level Award in 2007. The American Nurses Credentialing Centre approved it as a “Magnet Hospital for Excellence in nursing.” The NIHSS was primarily used by the PPMC in 2003 in relation to the introduction of new neuroscience unit. Adequate training is given to the floor nurses for using this system. In the centre the new system was part of the formalized stroke treatment and recovery program. The training and education on the NIHSS was provided on a wide scale by including the nursing staff in IC unit and emergency department. In the online training program, PowerPoint presentations and training tapes were used. In the department of neuroscience, the nursing staff used the tool daily for checking their patients’ stroke level and it seemed to be better, more efficient and comfortable in assessing the situation of patients. In the Emergency department and ICU this tool is not frequently used as the staff is not comfortable with the application of this tool as it seems to be time consuming and scary in nature. Due to lack of confidence, the nursing staff was reluctant to use the score measured by the tool and it is much different from the scores directly taken by the stroke physicians. In order to remove the complexity with the tool, it was modified with simplified language for representing each component of the tool. Proper training was given to the stroke physicians and nurses in the tool measurement. The modified tool was re-evaluated by the Providence Stroke Program Staff and they recommended for further simplification. And in 2005, the more simplified final tool was introduced. In order to measure the simplicity and validity of the scale measurement a comparative study was made by taking the sores of NIHSS versus SSPE on a correlation basis. It is estimated that a high correlation would indicate concurrent validity of the new tool measurement. The results on the comparative study revealed that the reliability of the two scales is high. The reliability of the SSPE is similar to that of NIHSS. The concurrent validity of the two scales demonstrated a very high score. These two scales demonstrated high reliability and validity scores in the measurement of stroke severity. The study on the efficiency of the NIHSS scale in measuring the stroke severity has revealed that it is a more reliable and valid tool in assessing the stroke level. The NIHSS is recognized as a most reliable stand alone tool for assessing the stroke severity in different types of stroke syndromes. “From study results and using several different testing measures, the SSPE is a highly reliable tool and comparable to the NIHSS. The SSPE also has high concurrent validity with the NIHSS, given that that NIHSS measures stroke severity.” (Dancer, Sandy, Brown, Allen, Yanase, & Rietz, 2009). Stroke: Stroke is the quickly increasing loss of brain function. The main reason of stroke is the disorder in the supply of blood to the brain. Lack of blood supply causes another disease by name ischemia caused by embolism. This decease affects whole of the body. This leads to lack of ability to move, see and communicate with each other. In ancient days the stroke was known as Cerebrovascular accident or CVA. But in the modern days it is known in the name of stroke. It can cause neurological complications and death. The important risk factors of stroke are old age, high blood pressure, diabetes, cholesterol, smoking etc. This is treated by using different kinds of therapy. They are speech and language therapy, physiotherapy and occupational therapy. Stroke syndrome is mainly caused by the impulsive death of a fraction of the brain cells in absence of oxygen. It occurs when the flow of blood to the brain is blocked by the result of abnormal and malfunction of the brain cell. Blood flow to the brain is mainly interrupted through blockage or rupture in the artery to the brain. Types of Strokes: - The strokes can be divided into two types. They are Ischemia and hemorrhagic. Ischemia happens with the breakage in supply of blood. These kinds of stroke are more common. The main reason of ischemic stroke is a lacunar infraction. It mainly arises in the case of older people with diabetes and uncontrolled high blood pressure. It can also be the consequence of any disorder that decreases the amount of blood or oxygen supplied to the brain. It indicates the low blood pressure. This stroke occurs in another condition when blood flow is at standard condition while that blood does not contain sufficient oxygen. Symptoms of ischemia stroke: 1. Loss of sight in one eye. That means powerlessness of the eyes. 2. Unusual feelings of hand and leg. 3. Inability of speech 4. lack of realization 5. Difficulty in swallowing Doctor suggests the remedial measures or diagnosis of this stroke. “Computed tomography (CT) is usually done first. CT helps distinguish an ischemic stroke from a hemorrhagic stroke, a brain tumor, an abscess, and other structural abnormalities. Doctors also measure the blood sugar level to rule out a low blood sugar level (hypoglycemia), which can cause similar symptoms. If available, diffusion magnetic resonance imaging (MRI), which can detect ischemic strokes within minutes of their start, may be done next.” (Ischemic stroke, 2009). Hemorrhagic stroke: - This means flow of blood within the brain. It is divided into two types. They are intracerebral hemorrhage and subarachnoid hemorrhage. Intracerebral hemorrhage is the consequence of high blood pressure. The main symptoms of this decease are the severe headache regularly throughout activity. In the case of older people this headache may be mild or deficient. Sometimes it affects one side of body through weakness and paralysis. The eyes may paralyze, causing vomiting etc. The doctor suggests two techniques to overcome this problem. They are Computed Tomography and magnetic resonance imaging. These two techniques help to identify the causes of this stroke. Subarachnoid Hemorrhage: This syndrome is characterized by a bleeding into the space (subarachnoid space). The bleeding mainly occurs in between the inner layer and middle layer of the tissue covering the brain known as meninges and it causes stroke in the patients. Prevention of stroke: Stroke is an important cause of death next to heart attack and cancer. In metropolitan area, where stroke is well known, the public must know that by using the 911 disaster telephone system they can be at the hospital faster. National Stroke Association advocate measures for prevention of stroke as follows. 1. Patients must test their blood pressure once in a year and maintain it under control. The major cause of stroke is uncontrolled blood pressure. It can be regulated be eating fresh fruits and vegetables, low salt and non fatty food items and reducing weight through exercise and treating immediately. 2. Identify the atrial fibrillation. Because it promote the creation of blood clots. It will create stroke. 3. Smoking is injurious to health. It develops full of fat deposits in the carotid arteries. It barriers the flow of blood to the brain. If the patient is smoker, he should stop smoking. 4. Patient must control the habit of drinking alcohol 5. If the patients suffers from cholesterol or any other problem; they should identify that and remove it fast through treatment. 6. If patient has diabetes, he must obey the advice of physician and control it. 7. Patient should regularly exercise and should have diet of low salt and low fat. 8. The important stroke symptoms are strong headache, severe pain in face and other part of the body. They should try to get urgent medical attention. 9. A TIA (transient ischemic attack) mainly results from the focal loss of brain function accredited to cerebral ischemia lasting for a period of less than 24 hours (usually 10-15 minutes) and it is always localized to a limited region of the brain mainly in the carotid artery distribution or basilar vertebral distribution. Risk Factors of Stroke: Certain circumstances can increase stroke risk. Those are known as risk factors. Some risk factors can be controlled through change of lifestyle, operation or medicines. The treated risk factors are hypertension; disease of heart, atherosclerosis, large red blood cell count, Transient ischemic attacks, sleep apnea etc. Hypertension is the very significant risk factor for stroke. Heart decease is another risk factor. It is reduced by controlling three important factors such as cigarette smoking, high cholesterol and blood pressure. Atherosclerosis is otherwise known as hardening of the arteries. It is a condition in which oily deposits develop on the inside walls of the arteries. Risk factors of stroke can be hereditary also. The important risk factors of stroke are age, race, gender, diabetes, heredity etc. etc. These factors cannot be altered. Age related stroke is common among people of 65 and above. Stroke can sometimes be genetic. African Americans have high scale of risk of death from a stroke. Gender related stroke is mainly seen more in men compared to women. So a higher number of deaths occur in the case of men. The main reason for the risk of stroke in women can be the use of birth control pills and pregnancy pose etc. Previous case of stroke can also cause death of a person. Transient Ischemic Attacks are considered as warning stroke. It introduces symptoms of stroke. TIA is recognized as a one of the important forecaster of stroke. The other well documented risk factors are geographic location, socioeconomic factors, alcohol abuse, drug abuse etc. Strokes are mainly in the southeastern United States. It is more in the case of poor people. Studies on National Institute of Stroke Scale: As more and more people in United States are affected by stroke, the quality of inpatient care for stroke patients should be given due consideration at the national level. It is estimated that about 700,000 people experience stroke every year and about $56.8 billion was incurred for projected direct and indirect treatment cost. 1. E.C Leira, H.P Adams Jr, G E Rosenthal, J.C. Torner has undertaken a study titled “Baseline NIH Stroke Scale Responses Estimate the Probability of Each Particular Stroke Subtype”. It is said that “different subtypes often are associated with specific patterns of neurological deficits, we hypothesize that scores on baseline NIH stroke scale (NIHSS) items may help emergently stratify patients by their probability of having a particular stroke subtype.” (Leira, Adams, Rosenthal, & Torner, 2008). On the basis of multivariate polytomous logistic regression analysis, the study was conducted with the following results : “The NIHSS items that discriminate between stroke subtypes are language, neglect, visual field and brachial predominance of weakness. Among patients without atrial fibrillation, a normal score for these 4 variables conveys a 46% chance of lacunar stroke, 12% of athero thrombotic stroke and 10% of cardio embolism. This pattern gradually reverses with increased numbers of abnormal responses. Those with abnormalities in all 4 items have a 0.1% chance of lacunar stroke, 50% of athero thrombotic stroke and 39% of cardio embolism.” (Leira, Adams, Rosenthal, & Torner, 2008). 2. Jenny Richardson, Diana Murray, C. Ken House, Ten Lowenkropf had made a study to access the severity of stroke in Successful Implementation of the National Institutes of Health Stroke Scale on a Stroke/Neurovascular Unit. The barriers of implementation of NIHSS. On the basis of survey among staff members interventions like staff education were created for the successful implementation of NIHSS. Pocket cards were used for the assessment of NIHSS and the result showed a positive increase from 12% to 69%, thus leading for the acute treatment of stroke. (Richardson, Murray, House, & Lowenkopf , 2009). 3. Linda S. Williams, MD; Engin Y. Yilmaz MD; PhD Alfredo M. Lopez Yunez, MD, has made a study titled Retrospective Assessment of Initial Stroke Severity with the NIH Stroke Scale to identify the severity of strokes and to assess the validity of the retrospective NIHSS. The research method was an algorithm with written history and physical administration notes of 32 stroke patients. Linear regression and Wilcoxon signed rank test were used for assessing the reliability and systematic scoring. The results was that “32 ischemic stroke patients were representative of our usual stroke population with mean (SD) age 63 (14) years; 50% were male. Mean NIH-P was 5.4 (median 3, range 0 to 24). Only 1 admitting H&P was complete for all NIHSS elements were complete except for the "extinction/inattention" element.” (Williams, Yilmaz, & Lopez-Yunez, 2000). It was also found that there was an 86% probability for the correct ranking in the NIH scores. There was an equal proficient at retrospective scoring with varying levels of stroke. It also points out the accuracy of NIHSS items in the retrospective assessment. Proposed best practices for teaching session: This teaching session is aimed to provide efficient and effective training to the nursing staff in the stroke treatment hospitals for the easy use of the NIHSS Scale. Through this teaching practice they will get adequate experience in handling the NIHSS tool for measuring the stroke severity. They will be more comfortable with the use of the tool and thus accurate measurement can be ensured. In this teaching session, the staff should get opportunity for expressing their personal expectations regarding the tool and the requirements from the tool for fitting with the patient criteria. Their specific roles in the effective implementation of the tool also have to set up in this teaching session. In this session the online version of the teaching is involved. In the online training course, detailed explanation on various segments is included for administering and scoring the NIHSS. Clear explanation with the assistance of video picture on doctors’ performing the NIHSS are involved in the online course and this will facilitate to provide better grasp on the usage of the scoring device. Instructional examples with illustration of each potential score should be provided with each scale item. The online course will benefit with repeated learning process. Exam on the NIHSS training has to be carried out by the strict guidelines of the National Stroke Association. The certification has to be standardized by a national agency. As a systematic stroke assessment tool better training should be provided to the nursing staff about the application of this tool as it will facilitate to get better results. . Annotated Bibliography: 1. Stroke Statistics. (2009). American Heart Association: Learn and Live. Retrieved June 11, 2009, from http://www.americanheart.org/presenter.jhtml?identifier=4725 This document explains statistics related to the Strokes in the United States in 2005. It is published by American Heart Association. It provides detailed information about the different sectors of stroke statistics in detailed manner by taking the figures in between 1995 to 2005. 2. Vega, J. (2009). How is the NIH stroke scale (NIHSS) used for the evaluation of stroke? About.com: Stroke. Retrieved June 11, 2009, from http://stroke.about.com/od/glossary/f/NIH_Scale.htm The main focus of this article was to review “how is the NIH stroke Scale (NIHSS) used for the evaluation of stroke?’. The author of the article is Dr. Jose Vega. This article mainly focused on the effectiveness of NIHSS as an evaluating tool for the stroke severity. The several purposes of NIHSS scale are discussed in this article. 3. Dancer., Sandy., Brown., Allen J., Yanase., & Rietz, L. (2009). National institutes of health stroke scale reliable and valid in plain English. Journal of Neuroscience Nursing. All Business: A D&B Company. Retrieved June 11, 2009, from http://www.allbusiness.com/company-activities-management/management-benchmarking/11782808-1.html The article, National Institutes of Health Stroke Scale reliable and valid in plain English focusses on the modifications that were made over the terminology in the NIHSS. The authors of this article are Dancer, Sandy, Brown, Allen J., Yanase and Lisa Rietzthe. In this article it is stated that the neurologic terminology in the tool is complicated and causes problems to the nurses. For removing this modification has been made by replacing the terminology with plain English. This article is a useful source for this paper as it gives literary review discussing the history and development of the NIHSS as a research tool. 4. Ischemic stroke. (2009). Merck. Retrieved June 11, 2009, from http://www.merck.com/mmhe/sec06/ch086/ch086c.html The article on Ischemic stroke written by Elias A. Giraldo is highly useful for collecting detailed information regarding the ischemic stroke and its symptoms. This article elaborately explains all the important facts relating to the Ischemic stroke starting from its causes and symptoms to diagnosis and prognosis. Treatment for this syndrome is also discussed in this article. Different causes for this syndrome are elaborately discussed by using diagrams. This article seems to be a significant source for doing the research on NIHSS as a stroke measuring tool. 5. Leira, E C., Adams, H P., Rosenthal G E., & Torner J C. (2008). Baseline NIH stroke scale responses estimate the probability of each particular stroke subtype: Abstract. Cerebrovascular Diseases, 26 (6), 573-577. Karger. doi: 10.1159/000165109 The article “Baseline NIH Stroke Scale Responses Estimate the Probability of Each Particular Stroke Subtype” result of the combined effort of by E.C. Leiraa, H.P. Adams Jr.a, G.E. Rosenthalb, J.C. Tornerc mainly focussses on the Cerbrovascular diseases. The review on their work provides information about the emergency treatment of acute stroke syndromes. Significance of the NIHSS in the clinical diagnosis of the stroke diseases is clearly specified in his review. The report is based on a research study conducted among the stroke patients. Data analyzed through regression techniques reveal that NIHSS meet all the necessary criteria of an effective stroke diagnosis tool. This review article is highly informative in the advantages and significance of NIHSS in the stroke diagnosis. 6. Richardson, J., Murray, D., House, C K., & Lowenkopf , T. (2009). Successful implementation of the national institutes of health stroke scale on a stroke/neurovascular unit. Medscape Today. Retrieved June 11, 2009, from http://www.medscape.com/viewarticle/550818 The article deals with the method for successful implementation of the NIH stroke scale methods. Several barriers constraining the effective implementation of NIH stroke scale are briefly stated in this article. Jenny Richardson, Diana Murray, C. Ken House, Ten Lowenkropf had made a study to access the severity of stroke in Successful Implementation of the National Institutes of Health Stroke Scale on a Stroke/Neurovascular Unit. The results of the study showed that the NIH stroke scale is a leading tool for the acute treatment of stroke. 7. Williams, L S., Yilmaz, E Y., & Lopez-Yunez A M. (2000). Retrospective assessment of initial stroke severity with the NIH stroke scale. Stroke, 31, 858-862. Retrieved from http://stroke.ahajournals.org/cgi/content/full/31/4/858?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=nihss&searchid=1&FIRSTINDEX=20&resourcetype=HWFIG This is a research study on the effectiveness of NIHSS on the clinical diagnosis of stroke. The research is focused on the stroke outcomes for differences in initial stroke severity. The research study is conducted through algorithm for retrospective NIHSS scoring. The data for the research is collected from 32 ischemic stroke patients. This article provides information on the NIHSS by comparing it with other stroke measuring tools. References Dancer., Sandy., Brown., Allen J., Yanase., & Rietz, L. (2009). National institutes of health stroke scale reliable and valid in plain English. Journal of Neuroscience Nursing. All Business: A D&B Company. Retrieved June 11, 2009, from http://www.allbusiness.com/company-activities-management/management-benchmarking/11782808-1.html Dancer., Sandy., Brown., Allen J., Yanase., & Rietz, L. (2009). National institutes of health stroke scale reliable and valid in plain English: Conclusions. Journal of Neuroscience Nursing. All Business: A D&B Company. Retrieved June 11, 2009, from http://www.allbusiness.com/company-activities-management/management-benchmarking/11782808-1.html Ischemic stroke. (2009). Merck. Retrieved June 11, 2009, from http://www.merck.com/mmhe/sec06/ch086/ch086c.html Ischemic stroke: Diagnosis. (2009). Merck. Retrieved June 11, 2009, from http://www.merck.com/mmhe/sec06/ch086/ch086c.html Leira, E C., Adams, H P., Rosenthal G E., & Torner J C. (2008). Baseline NIH stroke scale responses estimate the probability of each particular stroke subtype. Cerebrovascular Diseases, 26 (6), 573-577. Karger. doi: 10.1159/000165109 Leira, E C., Adams, H P., Rosenthal, G E., & Torner, J C. (2008). Baseline NIH stroke scale responses estimate the probability of each particular stroke subtype: Abstract. Cerebrovascular Diseases, 26 (6), 573-577. Karger. doi: 10.1159/000165109 Richardson, J., Murray, D., House, C K., & Lowenkopf , T. (2009). Successful implementation of the national institutes of health stroke scale on a stroke/neurovascular unit. Medscape Today. Retrieved June 11, 2009, from http://www.medscape.com/viewarticle/550818 Stroke Statistics. (2009). American Heart Association: Learn and Live. Retrieved June 11, 2009, from http://www.americanheart.org/presenter.jhtml?identifier=4725 Vega, J. (2009). How is the NIH stroke scale (NIHSS) used for the evaluation of stroke? The level of stroke severity as measured by the NIH stroke scale scoring system. About.com: Stroke. Retrieved June 11, 2009, from http://stroke.about.com/od/glossary/f/NIH_Scale.htm Vega, J. (2009). How is the NIH stroke scale (NIHSS) used for the evaluation of stroke? About.com: Stroke. Retrieved June 11, 2009, from http://stroke.about.com/od/glossary/f/NIH_Scale.htm Williams, L S., Yilmaz, E Y., & Lopez-Yunez A M. (2000). Retrospective assessment of initial stroke severity with the NIH stroke scale: Results. Stroke, 31, 858-862. Retrieved from http://stroke.ahajournals.org/cgi/content/full/31/4/858?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=nihss&searchid=1&FIRSTINDEX=20&resourcetype=HWFIG. Williams, L S., Yilmaz, E Y., & Lopez-Yunez A M. (2000). Retrospective assessment of initial stroke severity with the NIH stroke scale. Stroke, 31, 858-862. Retrieved from http://stroke.ahajournals.org/cgi/content/full/31/4/858?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=nihss&searchid=1&FIRSTINDEX=20&resourcetype=HWFIG Read More