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NIH Stroke Scale

NIH Stroke Scale. Hannah Dowling University of South Florida. 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. What is a stroke?.

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NIH Stroke Scale

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  1. NIH Stroke Scale Hannah Dowling University of South Florida

  2. 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 What is a stroke?

  3. Education is key!

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

  5. 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 When and how?

  6. 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 1a. Level of consciousness

  7. 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 1b. LOC Questions

  8. 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 1c. LOC Commands

  9. 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 2. Best Gaze

  10. 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 3. Visual

  11. 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) 4. Facial Palsy

  12. 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 5. Motor Arm

  13. Extend the leg 30° • Ask the patient to hold their leg for 5seconds • Count aloud and with your fingers (examiner) • 6a. Left Leg • 6b. Right Leg 0 = No drift; holds limb for 5seconds 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 6. Motor Leg

  14. 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 7. Limb Ataxia

  15. 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 8. Sensory

  16. 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 9. Best Language

  17. What is happening in this picture?

  18. Describe the objects in this picture

  19. Please read these sentences

  20. 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 10. Dysarthria

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

  22. 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 11. Extinction & Inattention

  23. 0 = no stroke • 1-4 = minor stroke • 5-15 = moderate stroke • 16-20 = moderate/severe stroke • 21-42 = severe stroke Scoring

  24. 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” Resources

  25. National Institutes of Health (2011). NIH Stroke Scale Certification. Retrieved from http://learn.heart.org/ihtml/application/student/interf ace.heart2/index2.html?searchstring=583 References

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