(Roa-monick)Stroke Recognition Scales

7/27/2019 (Roa-monick)Stroke Recognition Scales.

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Monique-Lorelyn A. Roa, RN


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Stroke definition:STROKE

is a

BRAIN ATTACK


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Stroke is: Sudden onset of focal

neurological deficitlasting for more than 24hours due to anunderlying vascularpathology


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EARLY HOURS OF STROKE: THE ROLE OF THE

PHYSICIANS IN ACUTE STROKE CAREAsk??? Is the hospital & its medical staff prepared and

equipped to provide stroke care?

The admitting medical personnel (ER PHYSICIAN)has the major responsibility to provide acute efficientstroke management is & early medical treatmentwhich can reduce the risk of death or disability from

stroke.When available: Refer to physician trained in stroke

care and admit to a stroke unit/ ICU


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THE ROLE OF THE PHYSICIANS IN

ACUTE STROKE CARE: Confirm not that the diagnosis is STROKE & not

mimickers; that the stroke is ISCHEMIC & notHEMORRHAGIC.

Determine if acute treatment with thrombolytic agent(r-tPa) is advisable

Do diagnostics to screen for acute medical or

neurological complications of stroke Determine vascular distributions of the stroke &

provide clues on likely pathophysiology & etiology.


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Emergency Room Management

Priorities Ascertain clinical diagnosis of stroke (history,

physical and neurologic exam) Exclude common stroke mimickers

Provide basic emergent supportive care (CABs =formerly ABC) Initial neurovital signs, BP, MAP, RR, T, pupils Monitor and manage BP. Treat if MAP> 130 Identify co-morbidities and Risk Factors Perform stroke scales (NIHSS, GCS, ROSIER) Provide O2 support to maintain O2 sat > 95% Ensure adequate hydration. Recommended IVF: 0.9%

Nacl


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EMERGENT DIAGNOSTICS: CBC w/ platelet count CBG or RBS

PT/PTT

Serum K and Na

ECG

Non contrast CT Scan of brain or MRI asap


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COMPUTE FOR MAP MAP = 2 (Diastolic) + Systolic

3Ex: BP= 220/110 mmHgMAP= 2 (110)+ 220 / 3

MAP= 146

Treatment should be done asap!!!


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TIME GOALSED Arrival Immediate general

assessment &stabilization

10mins

Immediateneurologicassessment bystroke team

25mins

Completion &interpretationof CT Scan

45mins

Reviewrisk/benefits of theneed forfibrinolytic therapyw/ patient & family

60minsStrokeAdmission

3

hours


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Recognition of Stroke Various stroke recognitions scales to aid in the fast diagnosis of

stroke for timely referral of appropriatepatients to acute strokeunits necessary for effective provisionof skilled care FAST

ROSIER Scale Glasgow Coma Scale (GCS) Cincinnati PrehospitalStroke Scale (CPSS)

Hunt and Hess National Institutes of Health Stroke Scale (NIHSS)

These were applied to first line services such as Paramedics, Ambulance staff, Emergency department Nurses and Physicians General practitioners in primary care hospitals


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ACT


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Face Does the face look uneven?Ask the person to smile.

Arm Does one arm drift down?Ask the person to raise both arms.

Speech Does their speech sound strange?Ask the person to repeat a simple phrase.

Time If you observe any of these symptoms, callfor help immediately


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CINCINNATI STROKE SCALE Evaluates three major physical findings:

Facial droop

Motor arm weakness Speech abnormalities

Patients with 1 of these 3 findings as a new event

72% probability of an ischemic stroke

Ifall 3 findings are present > 85% probability of an acute stroke


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Facial Droop


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Arm Drift Have the patient close his/her eyes and hold both arms

out for 10 seconds

Normal both arms move the same way, orboth armsdo not move at all.

Abnormal one arm does not move orone arm driftsdown compared to the other arm.


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ROSIER Recognition of Stroke in the Emergency Room (ROSIER)

scale

seven-item (total score from -2 to +5) stroke recognitioninstrument

constructed on the basis of clinical history

loss of consciousness, convulsive fits/seizures

and neurological signs

face, arm, or leg weakness, speech disturbance, visual field defect


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GLASGOW COMA SCALE


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SPERM MONITORING SENSORIUM- awake, drowsy, stuporous, comatose

PUPILS- measure both pupil size in mm; BR, SR, NR

EYE MOVEMENT- spontaneous full, spontaneouslimited, (+)/(-) dolls eye

RESPIRATION- regular normal (12-20 cpm), regularfast (>20 cpm), regular slow (


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The National Institutes of Health

Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative

measure of stroke-related neurologic deficit.

is a 15-item neurologic examination stroke scale used to

evaluate the effect of acute cerebral infarction on the levelsof consciousness, language, neglect, visual-field loss,extraocular movement, motor strength, ataxia, dysarthria,and sensory loss.

Ratings for each item are scored with 3 to 5 grades with 0 asnormal, and there is an allowance for untestable items. Thesingle patient assessment requires less than 10 minutes tocomplete.


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Language


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Summary:ACT FAST

COMPUTE MAP ACCURATELY!

USE THE STROKE RECOGNITION SCALES TIME IS BRAIN!!!!!

Source:Guidelines for the Prevention, Treatment and Rehabilitation of Stroke bythe SSP


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THANK YOU!

Documents

(Roa-monick)Stroke Recognition Scales