2 Canadian Neurological Scale: Training for Trainers Workshop An Introduction.

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www.heartandstroke.ca/profed

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 (>11) tended to be associated with favourable outcome – lower risk of poor outcome at 6 months

• Lower CNS scores (<9) 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 <90º

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”(dorsiflex hands)

• Support patient’s arms while applying pressure between wrist and knuckles

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Section A1, Distal Arms• Scores for Arms (distal)


Mild = 1.0 - can “cock-back” wrist, unable to opposepressure

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


• Thighs brought toward body

• Keeping knees flexed to 90º

• Push down on each thigh one at a time

• Scores for Legs (proximal)


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


• 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 FaceSymmetrical = 0.5

Asymmetrical = 0.0

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Section A2, Arms• Arms: Demonstrate and/or place patient’s 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.

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2 Canadian Neurological Scale: Training for Trainers Workshop An Introduction.

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