NIH Stroke ScaleHannah DowlingUniversity 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 loss1 = Partial hemianopia2 = Complete hemianopia3 = 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 movements1 = 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 seconds1 = Drift; limb drifts but does not hit bed2 = Some effort against gravity, drifts down to bed3 = No effort against gravity; limb falls4 = 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 bed2 = Some effort against gravity, leg drifts down to bed3 = No effort against gravity; limb falls4 = 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 upShould be a smooth, non-clumsy movement

• Test on both sides 0 = Absent1 = Present in 1 limb2 = Present in 2 limbsUN = 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 loss1 = mild-to-moderate sensory loss; feels dull pain; aware of being touched2 = 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 aphasia1 = Mild-to-moderate aphasia, some loss of fluency or comprehension2 = Severe aphasia; all communication is fragmented3 = 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 = Normal1 = Mild-to-moderate dysarthria, patient can be understood with some difficulty2 = Severe dysarthria; speech is unintelligible or patient is muteUN = 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 abnormality1 = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation2 = Profound hemi-inattention or extinction to more than one modality

Scoring

• 0 = no stroke • 1-4 = minor stroke • 5-15 = moderate stroke • 16-20 = moderate/severe stroke • 21-42 = 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

http://learn.heart.org/ihtml/application/student/interface.heart2/index2.html?searchstring=583