Standardizing the Frequency of Neurologic Assessment After Acute Stroke.

The National Institutes of Health Stroke Scale (NIHSS) is considered the standard for assessing neurologic status after an acute stroke. Currently, there is no guideline for when this assessment should be completed, nor is there consensus on how frequently or for how long.We initiated a quality improvement project that sought first to determine when and how often nurses at a variety of institutions in our multisite health care system completed the NIHSS assessment and then to identify the minimum frequency at which nurses should complete the assessment. After reviewing the literature and current practices and observing internal and external benchmarks, we set a new standard for all institutions in the system to follow.The new assessment frequency was based on patient condition and level of care, although that frequency would change if a patient showed new or worsening neurologic changes. The new standard was successfully implemented at all the primary and comprehensive certified stroke centers in our network. Ongoing monitoring confirmed that the frequency of NIHSS assessment met the needs of our patients and ensured staff adherence to the new practice.

Refining Neurobehavioral Assessment of the High-Risk Infant Using the NICU Network Neurobehavioral Scale.

Nurses caring for high-risk infants use advanced assessment skills to identify the nature of infant instability and to assure timely intervention. The NICU Network Neurobehavioral Scale (NNNS) is a comprehensive assessment of neurological integrity and behavioral function of infants at risk. Research evidence supports its validity and reliability for clinical and research use. The NNNS offers nurses a neurobehavioral assessment especially suited to high-risk and premature infants.

Neurological assessment by nurses using the National Institutes of Health Stroke Scale: implementation of best practice guidelines.

Assessment is an essential nursing skill that gathers clinical information to strengthen decisions about health interventions and priorities inpatient care delivery. Neurological assessment of the acute stroke survivor provides the cornerstone for early diagnosis, appropriate prognostic evaluation, and optimal management to obtain favourable patient outcomes. The nursing approach to neurological assessment has been enhanced in recent years through the development of new evidence-based assessment tools and the support of best practice guidelines. Based on gaps seen in clinical practice and current best practice guideline recommendations, neurological nurses from The Ottawa Hospital (TOH) identified the need to assess acute stroke survivors using a standardized neurological assessment tool. In 2004, a Registered Nurses of Ontario (RNAO) nursing advanced clinical practice fellowship provided the opportunity for the development of expertise in stroke assessment and establishment of recommendations for neurological nursing assessment at TOH. As a result, standards for nursing neurological assessment have been adopted at TOH using the National Institutes of Health Stroke Scale (NIHSS). This paper will review current evidence and best practice guidelines for neurological assessment. The significances of using the NIHSS for nurses in the context of the provision of acute stroke care will be presented. Knowledge transfer, application and evaluation of best practice guidelines (BPGs) in clinical nursing practice will also be discussed.

Implementation of the Canadian Neurological Scale on an acute care neuroscience unit: a program evaluation.

The Canadian Neurological Scale (CNS), a validated stroke assessment tool, was implemented for the neurological assessment of patients with stroke. The purpose of this study was to explore nurses' values and perceptions of best-practice guidelines (BPGs) and the CNS assessment, to evaluate the effect of a workshop and implementation process on nurses' self-efficacy for CNS use, to determine whether the workshop and implementation process met the needs of the nurses, and to evaluate the accuracy and appropriateness of CNS assessment documentation. Nurses reported moderate-to-strong awareness and use of BPGs and expressed the belief that BPGs were valuable; however, they had some difficulty accessing BPGs. At 3 months after the workshop, nurses reported using the CNS assessment in practice but said that it was not easy to use and that it was not useful as a patient status communication tool or for documenting neurological changes. Nurses were moderately confident while performing the CNS assessment before the workshop. Confidence increased immediately afterward (p < .0001), and then decreased slightly at 3 months. The majority of nurses said the workshop met their learning needs. A chart audit demonstrated that only 69% of patients appropriate for the CNS assessment were assessed with this tool. Although nurses are aware of BPGs, translating these changes into practice takes time and may require BPG modification to best fit the needs of the areas in which they will be used. When choosing a validated stroke assessment tool, clinicians must consider how often the tool will be used for assessments, particularly in the acute phase.

Perspectives on sedation assessment in critical care.

Multiple studies have been undertaken to show that neurofunction monitors can correlate to objective sedation assessments. Showing a correlation between these 2 patient assessments tools may not be the correct approach for validation of neurofunction monitors. Two different methods of assessing 2 different modes of the patient's response to sedation should not be expected to precisely correlate unless the desire is to replace one method with the other. We provide a brief summary of several sedation scales, physiologic measures and neurofunction monitoring tools, and correlations literature for bispectral index monitoring, and the Ramsay Scale and the Sedation Agitation Scale. Neurofunction monitors provide near continuous information about a different domain of the sedation response than intermittent observational assessments. Further research should focus on contributions from this technology to the improvement of patient outcomes when neurofunction monitoring is used as a complement, not a replacement, for observational methods of sedation assessment.

Pilot testing of the Starship Infant Neurological Assessment tool.

Neurological assessment can be a challenge in young children because of their physical, behavioral, and cognitive immaturity. The use of an infant neurological assessment tool allows nurses to easily perform a comprehensive neurological assessment. The Starship Infant Neurological Assessment (SINA) tool is a 21-item instrument designed for use with children under 2 years of age. This study tested its reliability. Four children under 2 years old were videotaped as they were assessed using the SINA. Seven nurses viewed the tapes and indicated their assessment on the tool. Interrater analysis using intraclass correlation coefficients demonstrated good reliability for 17 of 21 items. Areas for future development and research include addition of extra items and further testing.

Toward solving the sedation-assessment conundrum: bi-spectral index monitoring and sedation interruption.

The sedation-assessment conundrum is defined by two diametrically opposed goals: to maintain an appropriate level of sedation, and to obtain a comprehensive neurologic examination that most accurately reflects the patient's neurologic status. A case presentation leads to a discussion of over-sedation and under-sedation issues that impact the care of critically ill patients. This information is useful in understanding the many methods of assessing sedation and interpreting individualized patient responses to sedation. The use of bi-spectral index monitoring and periods of sedation interruption are discussed within the context of addressing the sedation-assessment conundrum.

Ontario regional stroke centres: survey of neurological nursing assessment practices with acute stroke patients.

A survey to explore which neurological stroke assessment scales were being used by nurses at all nine regional stroke centres (RSCs) in Ontario, and education strategies for implementation of the new scales was conducted in 2004. Findings revealed that nurses are moving away from reliance on the Glasgow Coma Scale (GCS) towards use of more standardized stroke severity scales to facilitate assessment, documentation, and care planning with acute stroke survivors. Scales used include the Canadian Neurological Scale and the National Institutes of Health Stroke Scale. Consistency in use between nurses was identified as an implementation challenge that was best addressed through integration of the scale into the process of care and documentation and bedside education.

Research to practice: nursing stroke assessment guidelines link to clinical performance indicators.

Stroke is the fourth leading cause of death in Canada and, each year, approximately 50,000 Canadians will suffer a stroke with a range of severities from mild, short duration symptoms to significant long-term disability or death. Of these 50,000 patients, at least 20,000 are hospitalized. Earlier this year, a core set of evidence-based performance indicators were identified by a national consensus panel that may be used to determine the quality of care provided to stroke patients in hospital during the acute phase of illness. Nurses play a critical role in stroke care across the continuum and recently published stroke assessment guidelines for nurses clearly describe key approaches to assessment and/or screening of stroke survivors. Many of the nursing assessments and/or screening actions recommended in the guidelines have direct or indirect associations with the recent performance indicators. This article describes where those relationships exist and the role nurses may play in determining overall performance for acute stroke patient care delivery during the hospitalization phase of the stroke continuum of care.

A neuron in a haystack: advanced neurologic assessment.

An advanced practice nurse (APN) often encounters patients with alterations in neurologic functioning, regardless of the practice setting. In many situations, the APN will be asked to perform the initial evaluation and determine if additional testing and consultation are indicated. For the APN who does not routinely encounter these patients, the experience may be challenging. This article presents an organized approach to the examination of patients with alterations in mentation and level of consciousness and considerations for differential diagnosis.