SARASOTA MEMORIAL HOSPITAL TITLE: ISSUED FOR: NURSING PROCEDURE NATIONAL INSTITUTE OF HEALTH Nursing DATE: REVIEWED: PAGES: PS1094 7/01 3/18 1 of 5 RESPONSIBILITY: RN, LPN PURPOSE: OBJECTIVE: DEFINITION: The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool that provides a quantitative measure of stroke-related neurologic deficit. The scale is used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcomes. To provide a reliable and well-validated objective scoring system for initial and serial assessments of stroke patients. The National Institute of Health Stroke Scale (NIHSS) is a standardized neurological examination intended to describe the neurological deficits found in large groups of stroke patients. It emphasizes key clinical features of the neurological exam, assesses changes in neurological status on subsequent exams, and establishes severity of stroke. The NIHSS is a systematic 11 item neurological assessment that has established test/retest and inter-rater reliability. Valid for predicting lesion size and can serve as a measure for stroke severity; Scores range from 0 (no deficit) to 42 (severe deficit); Simple, requires less than 10 minutes to complete; and quantifies neurological function. KNOWLEDGE BASE: 1. This scale can only be administered by the clinician who has a current NIH certification. 2. Administer stroke scale items in the order listed. 3. Record performance in each category after each subscale exam. 4. Do not go back and change scores. 5. Scores should reflect what the patient does, not what the clinician thinks the patient can do. 6. The clinician should record answers while administering the exam and work quickly. Except where indicated the patient should not be coached 7. This scale allows for screening and trending of key neurological functions.
TITLE: NATIONAL INSTITUTE OF HEALTH Page 2 of 5 EQUIPMENT: PROCEDURE: NIH Stroke Scale (SCM Flow Sheet/ paper if downtime) In SCM Flow Sheet, the score is automatically generated. All items must be completed in order to save the flowsheet. If using a paper flowsheet, the score must be tallied. Neurological Exam: 1a. Level of consciousness: This refers to attention to the environment. 0 - if alert, keenly responsive, attentive, even if endotrachial tube or Paralysis, or language barrier. 1 - drowsy, wakes to voice/light touch. 2 - stuporous, need persistent stimulus to stay awake. 3 - only if there is no movement or only reflexive movement. 1b. Level of consciousness Questions: Ask patient what their age is and what the current month is. There is no partial credit. Writing is allowed if intubated. Do not coach; take only first attempt. 0 - both questions right, first try. 1 - one question right 2 - aphasia, stuporous, both questions wrong, deeply comatose 1c. Level of consciousness commands: Ask patient to Open/close eyes and Grip/release the non-paretic hand. Credit may be given if attempt is made, but not completed due to weakness. May pantomime. If the patient can t do these commands, give him something he can do. Only the first attempt is scored. 0 - both commands, success or attempt. 1 - one command, success or attempt. 2 - incorrect or no attempt. 2. Best Gaze: Can use voluntary or doll s eyes. Use instructions, or moving around bed or oculocephalic maneuver. (This is an exception to the rule of using first response). 0 - normal, even if it takes the oculocephalic maneuver to elicit. 1 - abnormal finding in one or both eyes, gaze is
TITLE: NATIONAL INSTITUTE OF HEALTH Page 3 of 5 abnormal in one or both eyes, but forced deviation or total gaze paresis is not present. 2 - no eye movement to any stimulus. 3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat as appropriate. If patient blind from any cause, score 3. 0 - patient without loss in any visual field. 1 - partial field loss. 2 - complete hemianopia. 3 - blindness, bilateral hemianopia 4. Facial Palsy: When testing ask patient to show teeth/gums or smile, raise eyebrows. If they can t follow commands, see what they do when they grimace to pain. You may use pantomime. 0 - normal, symmetrical. 1 - minor paralysis ( mild, asymmetrical paralysis of lower face only). 2 - partial, some movement on affected side. 3 - complete unilateral paralysis or complete comatose or bilateral paralysis 5. Motor arm: If patient is in bed, ask them to hold arms up, palms down, at a 45-degree angle. Each limb is tested in turn beginning with the non-paretic arm. Drift is scored if the arm goes toward, but not to bed, in less than 10 seconds. Count out loud, encourage the patient. Try pantomime if needed. 0 - no drift. 1 - drift, the arm comes down in < 10 seconds, but does not hit bed. 2 - can t HOLD arm up, if examiner lifts it, but there is some effort/tone. 3 - can t LIFT arm off bed, but there is some movement. 4 - no movement. 6. Motor leg: Scored like arm, but time needed for no drift is only 5 seconds. Hold the leg at 30 degrees and always tested supine. Each limb is tested in turn, beginning with the non-paretic leg.
TITLE: NATIONAL INSTITUTE OF HEALTH Page 4 of 5 7. Limb ataxia: This section attempts to identify a unilateral cerebellar problem. Test with eyes open. Use finger to nose or heel to shin tests on both sides. Ataxia is scored present & out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. 0 - Normal, no ataxia. 1 - present in one limb, out of proportion to weakness. 2 - present in two limbs. 8. Sensory: Use a pinprick (a new safety pin, please). Just about anything between normal and total sensory loss is a 1. If a patient does not respond, is a quadriplegic, or in a coma, score as a 2. 0 - Normal, symmetrical sensation. 1 - partial loss of accurate sensation. 2 patient is unaware of being touched in the face, arm or leg 9. Best language: This is an exception to the first try rule. You are testing fluency and comprehension. The intubated patient should be asked to write. The patient in a coma will be scored a 3. 0 - Normal, no aphasia. 1 - can communicate fairly well, may be missing some words, without significant limitation on ideas expressed. 2 - communicates/understands poorly, requires much guesswork on the part of the examiner. 3 Mute, global aphasia. 10. Dysarthria: This test the mechanics of speaking. If you think the patient s clarity of speech is normal, use the word card to check. 0 - Normal, clear speech. 1 - can be understood with some difficulty. 2 - cannot be understood or does not speak. NA- not scored-only if patient is intubated
TITLE: NATIONAL INSTITUTE OF HEALTH Page 5 of 5 11. Extinction and inattention ( neglect ): Test all aspects - visual, tactile, auditory, personal inattention (does not recognize own hand), extinction to simultaneous bilateral stimulation. This may already be clear from your contact so far with the patient. Remember how to do bilateral stimulation and what extinction is. 0 - no neglect. 1 - Visual or tactile neglect (inattention). 2 - Profound hemi inattention or hemi inattention to more than one modality.(does not recognize own hand or orients to only one side of space) DOCUMENTATION: REFERENCE: NIH Stroke Scale Flowsheet in SCM Frequency of documentation per written NIH order and/or unit standard 1. National Institutes of Neurological Disorders and Stroke. NIH Stroke Scale. Retrieved February 26, 2018. http://ninds.nih.gov/doctors/nih_stroke_scale.pdf 2. http://stroke.nih.gov/resources/ REVIEWING AUTHOR (S): Benjamin Doepker, BSN,RN Disease Specific Coordinator Stroke Marilyn Kirchman, MSN, RN, CCRN, SCRN, Stroke Q.I. & Education Specialist Benny Kruger, MSN, RN, CCRN, CNN, Stroke Team Kelly Comingore, RN, BSN, CCRN, Critical Care Nursing in Professional Development APPROVAL: Clinical Practice Council 3/1/18