Canadian Neurological Scale: Training for Trainers Workshop An Introduction

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Canadian Neurological Scale Training for
Trainers Workshop An Introduction
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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.