NIH Stroke Scale Hannah Dowling University of South Florida

What is a stroke? Definition: “A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.” Types: Diagnostic Tests: Treatment: thrombolytics (tPa), supportive care, prevent further injury

Education is key!

NIH Stroke Scale - What is it? Devised by the National Institutes of Health (NIH) A standardized method to evaluate the severity of a stroke Used by healthcare providers internationally

When and how? Administer the items in order Avoid coaching the patient Accept their first attempt Work quickly, score as you go Time schedule: Baseline, 2 hours post treatment (tPA), 24 hours after initial symptoms, 7-10 days, 3 months

1a. Level of consciousness 0 = Alert 1 = Not alert, arousable by stimulation 2 = Not alert, obtunded; requires strong/painful stimulation to respond 3 = Reflex motor response only; totally unresponsive; flaccid Introduce yourself, ask patient how they are feeling Explain the purpose of the Stroke Scale Evaluate the LOC

1b. LOC Questions What month is it? How old are you? 0 = Answers both questions correctly 1 = Answers one question correctly OR patient cannot speak due to ET tube 2 = Answers neither question correctly

1c. LOC Commands Open and close your eyes Grasp and then release your hand (non-paretic) 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly

2. Best Gaze Hold up one finger Ask patient to follow your finger Move it from side to side Patient should not move their head 0 = Normal 1 = Gaze is abnormal in one or both eyes; partial gaze palsy 2 = Forced deviation or total gaze paresis

3. Visual Test peripheral vision by covering one eye and perform a finger count Test in 4 directions on each side Patient should look straight ahead (or at the examiner) 0 = No visual loss 1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral hemianopia

4. Facial Palsy Ask the client to: Show me your teeth/gums Open and close your eyes Raise your eyebrows 0 = Normal symmetrical movements 1 = Minor paralysis (asymmetric smile, flattened nasolabial fold) 2 = Partial paralysis (total or near-total paralysis of lower face) 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)

5. Motor Arm If patient is sitting: extend the arm 90° If patient is lying, extend the arm 45° Ask the patient to hold their arm for 10 seconds Count aloud and with your fingers (examiner) 5a. Left Arm 5b. Right Arm 0 = No drift; holds limb for 10 seconds 1 = Drift; limb drifts but does not hit bed 2 = Some effort against gravity, drifts down to bed 3 = No effort against gravity; limb falls 4 = No movement

6. Motor Leg Extend the leg 30° Ask the patient to hold their leg for 5 seconds Count aloud and with your fingers (examiner) 6a. Left Leg 6b. Right Leg 0 = No drift; holds limb for 5 seconds 1 = Drift; limb drifts but does not hit bed 2 = Some effort against gravity, leg drifts down to bed 3 = No effort against gravity; limb falls 4 = No movement

7. Limb Ataxia Finger-nose-finger: (Examiner moves finger unpredictably) Shin test: Right heel to left knee, slide the heel down to foot and back up Should be a smooth, non-clumsy movement Test on both sides 0 = Absent 1 = Present in 1 limb 2 = Present in 2 limbs UN = Amputation or joint fusion

8. Sensory Touch a safety pin to proximal portions of arms, legs, and face Eyes can be open Ask client to compare the two sides 0 = Normal; no sensory loss 1 = mild-to-moderate sensory loss; feels dull pain; aware of being touched 2 = Severe to total sensory loss

9. Best Language If client wears glasses, make sure they are wearing them! Assess language and comprehension Examiner may have an idea of language from the previous portion of the exam 0 = No aphasia 1 = Mild-to-moderate aphasia, some loss of fluency or comprehension 2 = Severe aphasia; all communication is fragmented 3 = Mute, global aphasia

What is happening in this picture?

Describe the objects in this picture

Please read these sentences

10. Dysarthria This tests clarity of speech Listen to slurring and ability to be understood Dysarthria = difficult speech 0 = Normal 1 = Mild-to-moderate dysarthria, patient can be understood with some difficulty 2 = Severe dysarthria; speech is unintelligible or patient is mute UN = Intubated or other physical barrier

MAMA TIP – TOP FIFTY – FIFTY THANKS HUCKLEBERRY BASEBALL PLAYER Please read these words out loud

11. Extinction & Inattention Client should close their eyes Alternately touch the right and left side (face, hands, and legs) Ask the patient which side is being touched Wait for a consistent response THEN touch the patient on both sides 0 = No abnormality 1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation 2 = Profound hemi-inattention or extinction to more than one modality

Scoring 0 = no stroke 1-4 = minor stroke 5-15 = moderate stroke = moderate/severe stroke = severe stroke

Resources learn.heart.org/nihss/ Apple App Store: NIHSS ($1.99) Google Play (Android): Pocket NIHSS ($0.99) YouTube: “NIH Stroke Scale Training” Medscape App: “NIH Stroke Score”

References National Institutes of Health (2011). NIH Stroke Scale Certification. Retrieved from ace.heart2/index2.html?searchstring=583