what do the numbers really mean?

NIHSSTimothy Hehr, RN MA

Stroke Program Outreach Coordinator

Allina Health

NIHSS

The National Institutes of Health Stroke Scale (NIHSS) is a tool used to objectively quantify the impairment caused by a stroke

- 11 items

- Score a specific ability between 0-4- Score of 0 indicates normal function- Higher score = greater impairment- Range from 0-42

NIHSS

• Developed by NIH as a tool for consistent measurement of stroke severity in research studies

• Now held as standard for stroke severity –though does have some weaknesses

• It is important for nurses to know what this score means in relation to caring for the stroke patient

Conducting the NIHSS

• Do not coach or help with tasks• May demonstrate for those unable to

comprehend verbal instructions• Score patients first effort (except with

language then it’s best attempt)• Should be scored in the order listed

1a. Level of Consciousness

Score Definition

0 Alert; keenly responsive

1 Not Alert; but arousable by minor stimulation to

obey, answer, or respond

2 Not Alert; requires repeated stimulation to attend, or

is obtunded and requires stroke or painful stimulation

to make movements.

3 Responds only with reflex motor or autonomic effects,

or totally unresponsive, flaccid, and flexic

1b. Level of Consciousness

Score Definition

0 Answers both questions correctly

1 Answers one question correctly

2 Answers neither question correctly

• Ask month and age - no partial credit for being close

• Aphasic and stuporous- score 2• Unable to speak d/t intubation, trauma,

other- score 1

1c. Level of Consciousness

• Ask patient to open and close eyes• Make a fist and release it• If no response to verbal command -

demonstrateScore Definition

0 Performs both tasks correctly

1 Performs one task correctly

2 Performs neither task correctly

2. Best Gaze

• Only horizontal eye movements tested

Score Definition

0 Normal

1 Partial gaze palsy ; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present

2 Forced deviation , or total gaze paresis is not overcome by the oculocephalic maneuver

3. Visual

• Occipital cortex• Visual fields are tested by confrontation,

finger counting, or visual threat, as appropriate

Score Definition

0 No visual loss

2 Partial hemianopia

3 Complete hemianopia

4 Bilateral hemianopia (blind, including cortical

blindness)

4. Facial Palsy

• Ask patient to show teeth or raise eyebrows and close eyes

• Look for symmetry of grimace• Pearl: Bells Palsy and eyebrows?!

Score Definition

0 Normal

1 Minor Paralysis (flattened nosalabial fold, asymmetry on smiling

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 a) Left arm b) right arm

• Greater weakness in Middle Cerebral Artery (MCA) than Anterior Cerebral Artery (ACA) strokes

• Extend the limb (palms down) • 90 degrees if sitting, 45 degrees of supine• Begin in non-paretic arm

Score Definition

0 No drift ; holds limb for full 10 sec

1 Drift ; holds limb, but drift before 10 sec, but does not hit bed or other support

2 Some effort against gravity ; cannot get to or maintain degrees, drifts down to bed, but has some effort

3 No effort against gravity ; limb falls

4 No movement

UN Amputation or joint fusion, explain:

6. Motor Lega) Left leg b) Right leg

• Greater weakness in ACA than MCA strokes• Place limb in appropriate position• Always tested supine- leg to 30 degrees• Begin with non-paretic limb

Score Definition

0 No drift ; leg holds 30 degree position for full 5 seconds

1 Drift ; leg falls by the end of 5 secs but does not hit bed

2 Some effort against gravity ; leg falls to bed by 5 secs but has some effort against gravity

3 No effort against gravity ; leg falls to bed immediately

4 No movement

UN Amputation or joint fusion, explain:

7. Limb Ataxia• Cerebellar• Aimed at finding evidence of unilateral

cerebellar lesion• Test with eyes open• Finger-nose-finger and heel-shin tests

Score Definition

0 Absent

1 Present in one limb

2 Present in two limbs

UN Amputation or joint fusion, explain:

8. Sensory• MCA• Sensation or grimace to pinprick• Withdrawal from noxious stimulus (if obtunded or

aphasic)• Arms (not hands), legs, trunk, face• Patients in coma = 2

Score Definition

0 Normal , no sensory loss

1 Mild–to-moderate sensory loss ; feels pinprick is less sharp or dull on the affected side; loss of superficial pain, but is aware of being touched

2 Severe or total sensory loss ; is not aware of being touched in the face, arm and leg

9. Best Language• Left MCA [Broca (receptive) and Wernicke

(expressive)]• Looks for comprehension and can be obtained from

all the other tests• Can describe what is happening in pictures• Can name items, or read from list

Score Definition

0 No aphasia ; normal

1 Mild-to-moderate aphasia ; some obvious loss of fluency or facility of comprehension; reduction of speech or comprehension that makes conversation difficult

2 Severe aphasia ; all communication through fragmentary expression; great need for interference, questioning, and guessing by reviewer.

3 Mute, global aphasia ; no usable speech or auditory comprehension

10. Dysarthria

• Read or repeat words (can use list)

Score Definition

0 Normal

1 Mild-to-moderate dysarthria; patient slurs at least

some words, at worst, can be understood with some

difficulty

2 Severe dysarthria; speech slurred to be unintelligible,

is mute/anarthritic

UN Intubated, or other physical barrier, explain:

11. Extinction and Inattention(Formerly neglect)

• Often Rt MCA• May be obtained during prior testing• Since abnormality is scored only if present, the

item is never untestable

Score Definition

0 No abnormality

1 Visual, tactile, auditory, spatial, or personal inattention ; or extinction to bilat stimulation in one of the sensory modalities

2 Profound hemi-inattention or extinction to more than one modality ; does not recognizeone hand or orients to only one side of space

New Onset? Quick & Simple

22

STROKE CODE ACTIVATION

• S/S of stroke, • FAST• Confirm BG• Last Known Well

< 6 hours?

23

Activate your stroke code team!

Stroke Neurologist responds/pt expedited to CT Treatment initiated

Goal < 60 minutes to treat

TEAM EFFORT!!

References:

National Institute of Neurological Disorders and Stroke; (2003). Retrieved from: http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale.pdf

SPECIAL THANKS to Shelby Hehr – our Stroke Patient for the day!