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Canadian Neurological Scale: Training for Trainers Workshop An Introduction

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... Acute Care Guide: Day 2 ... Training for Trainers Workshop An Introduction Thanks The Heart and Stroke Foundation of Ontario gratefully acknowledges ... – PowerPoint PPT presentation

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Title: Canadian Neurological Scale: Training for Trainers Workshop An Introduction


1
(No Transcript)
2
Canadian Neurological Scale Training for
Trainers Workshop An Introduction
3
Thanks
  • The Heart and Stroke Foundation of Ontario
    gratefully acknowledges the contribution of
    Rhonda McNicoll, R.N., BSc.N., CNN(c), Hamilton
    Health Sciences, in the development of this
    presentation.

4
Canadian Neurological Scale (CNS)
  • Performing ongoing neurological assessment
    provides a standardized method to detect
    neurological deterioration that can lead to early
    intervention
  • Canadian Neurological Scale is a tool that has
    been recommended by the HSFO Best Practice
    Guidelines for Stroke Care, 2003 as a valid and
    reliable standardized measure for assessment of
    neurological deficits in the acute stroke period
  • Developed in 1985 in Montreal
  • Focuses on assessment of patients with acute
    stroke
  • Measures impairment

5
Canadian Neurological Scale, cont
  • Glasgow Coma Scale assesses patients with acute
    neurological nervous system dysfunction resulting
    in coma
  • CNS provides a complementary scale to assess
    conscious and aphasic patients
  • Well tested for reliability and validity
  • Suitable for prognostic stratification in trials
    and planning rehabilitative measures for patients
  • Higher CNS scores (gt11) tended to be associated
    with favourable outcome lower risk of poor
    outcome at 6 months
  • Lower CNS scores (lt9) tended to be associated
    with increased death, morbidity

6
Advantages of the CNS
  • Standardized
  • Reliability and validity well described
  • Sensitive to relevant changes in patients
  • Can be done repeatedly at bedside for acute
    patients
  • Uses simple and non-ambiguous definitions for
    each modality tested
  • Uses a minimum number of grades per modality
  • Addresses issue of aphasia

7
Frequency of Neurological Assessment Using CNS
  • The Heart and Stroke Best Practice Guidelines for
    Stroke Care outlines the frequency of assessing
    neurological status based on different clinical
    situations to assist organizations to set
    individual protocols based on specific patient
    needs
  • Individuals with acute ischemic stroke receiving
    t-PA
  • (pg 76, 124-125)
  • Monitor vital signs and CNS q15 minutes during
    drug administration
  • Post infusion care (24 hours)
  • Monitor CNS q1hour for 24hours
  • OR
  • More frequently as ordered, e.g. q15 minutes
    for 2 hours,
  • q30 minutes for 6 hours, q1hour for 16 hours

8
Frequency of Assessment Using CNS cont
  • Based on Heart and Stroke Best Practice
    Guidelines for Stroke Care
  • Individuals with acute ischemic stroke not
    receiving t-PA (pg 78)
  • Monitor vital signs and CNS q1hour for 24 hours
    or more frequently if ordered
  • Definitive or Suspected TIA Care Pathway and Plan
    (pg 114)
  • Monitor vital signs and CNS q2hours and prn
  • Acute Care Guides First 24 hours (pg 82)
  • Follow t-PA protocol if indicated
  • Assess vital signs and CNS q4hours

9
Frequency of Assessment Using CNS cont
  • Based on Heart and Stroke Best Practice
    Guidelines for Stroke Care
  • Acute Care Guide Day 2 (pg 84)
  • Assess vital signs and CNS q4hours
  • Acute Care Guide Day 3 (pg 86), Day 4-6 (pg 88)
  • Assess vital signs and CNS as required due to
    patient status
  • These care guides that are meant to provide
    recommendations based on the best evidence,
    however, always follow physician orders or
    clinical pathway guidelines for your organization

10
Canadian Neurological Scale
  • 11.5 point scale that has three components
  • Section A Mentation (LOC, Orientation, Speech)
  • Section A1 Motor function -- no comprehension
    deficit
  • Section A2 Motor function -- with comprehension
    deficit

11
Getting Started
  • Assess Pupils
  • Size and light reaction
  • Vital Signs (BP, T, P, R, Oximetry)
  • Assess Level of Consciousness
  • Alert or drowsy ? CNS
  • Stuporous/comatose ? GCS
  • Assess Orientation
  • Assess Speech
  • Assess Motor
  • No receptive deficit
  • With receptive deficit

12
Definition of Terms
  • Alert awake and alert, normal level of
    consciousness
  • Drowsy rouses when stimulated verbally, remains
    awake and alert for short periods but tends to
    doze
  • Stuporous responds to loud verbal stimuli and/or
    strong touch may vocalize, but does not
    completely wake up
  • Comatose responds to deep pain purposeful
    movement, non-purposeful movement, no response

13
Section A Mentation
  • Level of Consciousness
  • Alert or drowsy
  • If patient is Alert score 3.0
  • If patient is Drowsy score 1.5
  • Orientation
  • Where are you (city and hospital)?
  • What is the month and year?
  • Patient can write answers to questions of
    orientation
  • If the patient cannot state both place and time
    score Disoriented or not applicable score - 0.0

14
Section A Speech
  • Assess for Receptive Deficit
  • Ask patient to close eyes
  • Point to ceiling
  • Does a stone sink in water?
  • If patient does not complete all three, score
    receptive deficit 0.0, do not assess Expressive
    Deficit and go to Section A2 Motor Response
    Receptive Deficit Present
  • If no receptive deficit Assess for Expressive
    Deficit

15
Section A Speech
  • If no receptive deficit Assess for Expressive
    Deficit
  • Assess for Expressive Deficit
  • Name 3 objects and the use of each key, pencil,
    watch
  • If cannot name all 3 objects and the use of each
    Score Expressive Deficit 0.5
  • If the patient writes the responses, this is NOT
    acceptable as speech is being assessed
  • If the patient is slurred but intelligible, that
    is acceptable for normal speech. Indicate SL
    when scoring normal speech
  • If no Expressive Deficit, score Normal Speech
    1.0
  • If the patient has an Expressive Deficit or
    Normal Speech go to Section A1 - Motor Response
    (No Receptive Deficit)

16
Section A1 Motor Response (No Receptive Deficit)
  • Complete this section if patient has an
    Expressive Speech Deficit or Normal Speech
  • Face Ask patient to smile or show teeth or gums
  • Note asymmetry of mouth and nasal labial folds
  • Scores for Face
  • No weakness score None 0.5
  • Weakness score Present 0.0
  • Note Record the side exhibiting the WORST
    deficit, using R or L

17
Section A1, Proximal Arms
  • Note Submit both arms to the same testing.
    Record the side exhibiting the WORST deficit,
    using R or L
  • Arm (proximal)
  • If patient is sitting lift arms to shoulder
    level (90º) and apply resistance just above
    elbows bilaterally
  • If patient is in lying in bed elevate arms to
    90º and apply resistance above elbows bilaterally

18
Section A1, Proximal Arms
  • Scores for Arms (proximal)
  • None 1.5 - no weakness
  • Mild 1.0 - movement to 90º, unable to oppose
    pressure
  • Significant 0.5 - movement lt90º
  • Total 0.0 - absence of motion

19
Section A1, Distal Arms
  • Arms (distal) Patient sitting or lying
  • Submit both arms to the same testing. Record the
    side exhibiting the WORST deficit, using R or
    L
  • Arms outstretched with wrists cocked-back(dorsi
    flex hands)
  • Support patients arms while applying pressure
    between wrist and knuckles

20
Section A1, Distal Arms
  • Scores for Arms (distal)
  • None 1.5 - no weakness
  • Mild 1.0 - can cock-back wrist, unable to
    oppose pressure
  • Significant 0.5 - some movement of fingers
  • Total 0.0 - absence of movement

21
Section A1, Proximal Legs
  • Legs (proximal) Patient lying in bed
  • Submit both arms to the same testing. Record the
    side exhibiting the WORST deficit, using R or
    L
  • Thighs brought toward body
  • Keeping knees flexed to 90º
  • Push down on each thigh one at a time
  • Scores for Legs (proximal)
  • None 1.5 - no weakness
  • Mild 1.0 - can lift leg, unable to oppose
    pressure
  • Significant 0.5 - lateral movement but no power
    to lift leg
  • Total 0.0 - absence of movement

22
Section A1, Distal Legs
  • Legs (distal) Patient lying in bed
  • Submit both arms to the same testing. Record the
    side exhibiting the WORST deficit, using R or
    L
  • Toes and feet pointed upward
  • Push down on each foot, one at a time
  • Scores for Legs (distal)
  • None 1.5 - no weakness
  • Mild 1.0 - can point foot toes upward, unable
    to oppose pressure
  • Significant 0.5 - some movement of toes, but
    cannot lift toes or foot
  • Total 0.0 - absence of movement

23
Section A2 Motor Response(Receptive Deficit
Present)
  • Complete this section if patient has a Receptive
    Speech Deficit only
  • Face Have patient mimic your own grin, show his
    teeth or gums
  • Note asymmetry of mouth and nasal labial folds
  • If patient is unable to cooperate, observe facial
    response when pressure is applied to sternum
  • Note Record the side exhibiting the WORST
    deficit, using R or L
  • Scores for Face
  • Symmetrical 0.5
  • Asymmetrical 0.0

24
Section A2, Arms
  • Arms Demonstrate and/or place patients arms
    outstretched in front of patient at 90º
  • If patient is unable to cooperate, apply finger
    nail bed pressure bilaterally and compare
    response
  • Note Submit both limbs to the same testing.
    Record the side exhibiting the WORST deficit,
    using R or L
  • Scores for Arms
  • Equal 1.5 - equal motor response
  • Unequal 0.0 - unequal motor response

25
Section A2, Legs
  • Legs thighs toward trunk with knees flexed to
    90º
  • If patient is unable to cooperate, apply toenail
    bed pressure bilaterally and compare response
  • Note Submit both limbs to the same testing.
    Record the side exhibiting the WORST deficit,
    using R or L
  • Scores for Legs
  • Equal 1.5 - maintain position or withdraw
    equally
  • Unequal 0.0 - cannot maintain position or
    unequal withdrawing

26
Scoring the CNS
  • Score Mentation Section -Section A for all
    patients
  • Score Section A1 OR Section A2
  • Do not score both A1 A2
  • Add Section A A1 OR A A2
  • Maximum Score 11.5
  • Decrease of more than 1 point from previous CNS
    scores is indicative of a change in patient
    status and requires notification of the
    physician. Changes in vitals signs and pupil size
    and reaction would also warrant a change in
    status and also require notification of the
    physician.
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