NIH Stroke Scale
NIHSS Education Notes
Introduction:
The NIH Stroke Scale is to be completed on patient arrival, 1 hour post tPA infusion, at 3 hours, 6 hours and
12 hours, then every shift or change in neurological status throughout the acute phase (7-10 days). This scale
should be completed by nursing.
Scoring Ranges:
0 - 8 = Mild Stroke
8 – 15 = Moderate Stroke
> 15 = Severe
Note: Some stroke neurologists define a severe stroke as > 20 therefore it depends on the neurologist.
NIHSS - DVD
1a)
Level of Consciousness
Test: To determine if the patient is alert ask them two or three questions about their admission, if
they are in pain, or if they are comfortable?
Hint: May have to stimulate patient by patting or rubbing the patient, or a more noxious stimulant
may be needed to determine alertness.
Score :
0 - Alert & responsive
1 - Arousable to minor stimulation
2 - Arousable only to painful stimulation
3 - Reflex response or unarousable
Notes:
An alert patient is vigilantly attentive and keen. A drowsy patient rouses when stimulated verbally
and remains awake and alert for short periods but tends to doze. A lethargic patient is dull, sluggish
and appears half asleep.
An obtunded patient (Obtunded: Mentally dulled). A person may be obtunded due to head trauma.
To obtund is to dull or blunt. (From the Latin obtundere, to blunt) opens their eyes, responds slowly to
questions, is somewhat confused, and has a decreased interest in their environment.
A stuporous patient is near unconscious with apparent mental inactivity and reduced ability to
respond to stimulation, may respond to loud or verbal stimuli and/or strong touch; may vocalize but
does not completely wake up. A comatose patient is unconscious, may respond to deep pain with
purposeful movement, non-purposeful movement or no response.
Reflex posturing
1b)
LOC Questions
Test : Ask the patient the month and his/ her age.
Hint: If the patient is awake and seems like they understand what you are saying but cannot talk they
get a score of 1. If the patient is unconscious or can’t comprehend/speak they get a score of 2. Score
a 2 if you have scored a 3 in item 1a.
Score :
0 - Both correct
1 - One correct (dysarthria, intubated, foreign language)
2 - Neither correct
Notes :
Just because the patient may not be able to speak the patient may be able to write. Remember we
are determining LOC.
Pt may have severe dysarthria (unintelligible speech) or aphasia (loss of ability to express one’s
thought in speech/writing or both)
You could give the patient a calendar or write down a list of months and have the patient point at the
appropriate name date etc.
Always take first response.
1c)
LOC Commands
Test: Ask the patient to open and close their eyes and then grip and release the non-paretic hand.
Hint: A patient whose commands have to be changed due to trauma, amputation or other physical
impediments need to be documented in the nursing notes so the assessment can remain consistent.
Score:
0 - Obeys both correctly (ok if impaired by weakness)
1 - Obeys one correctly
2 - Incorrect
Notes :
2.
Want hands in stable position.
Credit should be give when attempt is made.
Best Gaze
Test :
Move finger horizontally from midline to the left then back to midline then midline to the right and
back to midline. If this is not achievable perform the occulocephalic maneuver or known as the doll’s
eye sign.
Hint:
Consider if the eye movements are normal, if so score a 0.
If not, consider is there is tonic deviation (the eyes cannot be moved) score a 2.
Everything else is scored a 1.
Score:
0 - Normal
1 - Partial gaze palsy (abnormal gaze in 1 or both eyes)
2 - Forced deviation or total paresis which cannot be overcome by Dolls.
Notes :
The technique of testing oculocephalic reflex involves keeping the eyes of the patient open and then
rotating the head briskly from one side to the other. In cases where the brainstem of the patient is
intact the gaze deviates contra laterally and the patient looks away from rotation. In cases where the
brainstem of the patient is injuired, eyes follow the direction of the head movement. In aphasic
patients do not do occular celphalic manueuver.
3.
Visual Fields
Test :
Each eye is tested independently by finger movement. To perform the assessment ask the patient to
look at your nose and cover one of the patients eyes (patient can cover own eye if able), then hold up
fingers and ask how many fingers are seen or if patient can see fingers wiggling. Go around head (in
peripheral vision field) displaying different amounts of fingers.
(R) superior quadrantanopia
(Partial hemianopia)
Hint:
While performing this assessment you are testing all four quadrants of
the eye. If this patient is aphasic or unable to respond to following
your finger or following you around the room then you need to test
each eye independently by confrontation (visual threat) in all four
quadrants.
It is also important to be aware of their peripheral vision. When
testing ensure you are testing within their normal range of peripheral
vision.
Score:
0 - No loss
1 - Partial hemianopia
2 - Complete hemianopia
3 - Bilateral hemianopia or blindness
Notes:
Hemianopia - blindness in one half of the visual field in one eye.
Partial Hemianopia or Quadrantanopia - blindness in one fourth of the visual field.
Complete Hemianopia - affecting an entire half of the visual field (can be one eye).
Types of Hemianopia:
Bilateral hemianopia: loss of vision in the outer half of both the right and left visual field.
4.
Facial Palsy
Test :
Ask the patient to show me your teeth. Raise eyebrows and close eyes.
Hint:
The best way to assign a score is to determine if the patients face is normal.
If the face is not normal ask yourself if there is clear cut asymmetry of the smile if so score a 2.
Score:
0 - Normal
1 - Minor asymmetry
2 - Partial (lower face paralysis)
3 – Complete
A score of 3 is given if there is complete facial paralysis.
Notes:
If the face is completely normal with no changes score a 0, if you notice mild asymmetry, for example
slight down turn of the mouth when smiling, score a 1, if there is significant facial droop visible in just
the mouth and lower face, score a 2. If there if both upper and lower facial paralysis score a 3.
5
A & B Motor Arm
Test :
The arm is extended palm down 90 degrees if sitting or 45 degrees if supine, ask patient to hold arm
in position and count to 10.
Hint: Sometimes when the arm is let go it will drift down slightly. This should not be counted unless it
continues to drift.
To differentiate between a score of 3 or 4 try and encourage the patient to move the paretic limb, i.e.
shrug shoulders, tickle palm of hand, or use noxious stimuli (pushing on nail bed). Any movement at
all can lower a score from a 4 to a 3. Always count with fingers in full view of the patient (applies to
#6 as well).
Score :
0 - No drift x 10 seconds
1 - Drift but doesn’t hit bed
2 - Some effort against gravity but can’t sustain
3 - No effort against gravity but minimal effort counts
4 - No movement at all
UN - Amputation, joint fusion
Notes :
Some effort against gravity would be represented as a shrug of the shoulder or similar so this would
be scored as a 3 as opposed to no effort at all which is a 4.
It is important not to let the limb drop harshly. If you suspect the patient will have poor strength,
ensure you are ready to support it if they cannot, as this can lead to long term shoulder issues.
It is important not to coach the patient during this time and simultaneous testing should also not be
done.
Using a score of 9 is no longer used if unable to test. It is import for people with amputations or joint
fusion to score UN to ensure consistency of scoring.
6
Always start with non paretic arm.
A & B Motor Leg
Test:
The leg is extended 30 degrees in the supine position. Ask patient to hold leg and count to 5.
Hint:
To differentiate between a score of 3 or 4 try and encourage the patient to move the paretic limb, i.e.
flex hip flexor, try and move knee, tickle bottom of foot, use noxious stimuli (pushing on nail bed).
Any movement can lower score from a 4 to a 3.
Score:
0 - No drift x 5 seconds
1 - Drift but doesn’t hit the bed
2 - Some effort against gravity but can’t sustain
3 - No effort against gravity but minimal movement counts
4 - No movement at all
UN - Amputation, joint fusion
Notes :
Ensure not to extend the leg too far, take into consideration arthritis, flexibility and age when
performing the test.
Count out loud and use fingers to count.
Again do not let the limb drop.
Score an amputated limb or limb fusion at UN not 9.
7.
Limb Ataxia
Test :
Ask patient to “touch your finger to your nose. Now touch my finger then back to your nose”. Next
touch your heel to your shin go down your leg, now go back up”. Test with eyes open.
Hint:
Do not score ataxia in the patient who cannot comprehend a command or who has a pelagic limb.
Give them a 0. Explain why patient was given the score in the nursing notes.
Score :
0 - Absent (or aphasic or hemiplegic)
1 - Present in upper or lower exremity
2 - Present in both
Notes :
In this test we are scoring coordination rather than weakness therefore you should only score deficit
that is out of proportion to paralysis.
Score 0 if movement is smooth and accurate.
Score 1 if there is a slight ataxia with either the foot & shin or finger and nose alone.
Score 2 if difficulty is had with both.
Dysmetria - an aspect of ataxia in which the ability to control the distance, power and speed of an
act is impaired. Usually used to describe abnormalities of movement caused by cerebella disorders.
Typified by the undershoot and or overshoot of intended position with the hand, arm or leg. Difficult
to measure, can be described as an inability to judge distance or scale.
Dysnergia – in ability to coordinate voluntary muscle movements; unsteady movements or staggering
gate.
8.
Sensory
Test :
Tested with pinprick. Tap gently on face, arms and legs. Comparing sensation throughout bilaterally.
Only sensory loss attributed to the stroke is scored as abnormal.
Hint:
Do not test on the hands or feet – sensation may already be altered.
Score:
0 - Normal
1 - Unilateral loss- pt aware of touch (or aphasic confused)
2 - Total loss – pt unaware of touch, bilateral loss
Notes:
If sensation is normal bilaterally then score 0.
If sensation loss to one side is mild then score 1.
If sensation loss is severe then score 2.
9.
Best Language
Test :
Use the cookie jar pictures, the pictures of objects and the sentence list (refer to handout #4). Ask
the patient to: “describe what you see, name the items in this picture and read these sentences.”
Hint:
If patient has visual loss place objects in patients hand and ask to identify.
Also ensure cards are within clients known field of vision.
Ask intubated or trached patient to write.
Score:
0 - No aphasia
1 - Mild-Moderate aphasia (difficult but partly comprehensible)
2 - Severe aphasia
3 – Mute
Notes:
You should only encourage the patient and remember not to coach.
Remember you are testing comprehension not articulation of speech.
Score:
0 - if no aphasia
1 - for mild aphasia – loss of fluency or some difficulty finding certain words.
2 - Score 2 for Sever fragmented speech
Give the score of 3 to a patient who is in a coma or has global aphasia.
10.
Dysarthria
Test:
Using the simple word test, ask the patient to: “read these words”.
Hint:
Can usually be determined from prior testing. If patient cannot read you can say the words to them
and have them repeat them back. This item is only untestable if the patient is trached or has other
physical barriers to producing speech. Remember to document in the nursing notes.
Score:
0 - Normal articulation
1 - Mild-Moderate slurring (slurred but intelligible)
2 - Severe, unintelligible or worse
Notes:
Here you are testing articulation of speech
11.
Extinction & Attention ( Formally Neglect)
Test :
To perform this assessment have the patient close their eyes and ask the patient to distinguish what
side you are touching the patient on; left side, right side or both.
This exam helps to distinguish tactile extinction.
Another assessment is to check the patient’s peripheral vision with both eyes open, by wiggling
fingers and having that patient distinguish if it is the left side, right side, or both sides that the fingers
are wiggling.
This exam helps to distinguish visual extinction.
Hint : In certain cases you will have been able to determine if neglect is present from the other
assessments in the NIHSS.
Score :
0 - No neglect
1 - Partial neglect
2 - Profound neglect
Notes:
Hemispatial neglect : a neurological condition in which an individual does not attend to one side of
the body or visual field.
After damage to one hemisphere of the brain, a deficit in attention to and awareness of one side of
space is observed. Hemispatial neglect is very commonly contralateral to the damaged hemisphere,
but instances of ipsilesional neglect (on the same side as the lesion) have been reported.
Neglect most commonly results from brain injury to the right cerebral hemisphere, causing visual
neglect of the left-hand side of space. Right-sided spatial neglect is rare because there is redundant
processing of the right space by both the left and right cerebral hemispheres, whereas in most leftdominant brains the left space is only processed by the right cerebral hemisphere. Although most
strikingly affecting visual perception ('visual neglect'), neglect in other forms of perception can also be
found, either alone, or in combination with visual neglect
Visual Neglect:
Note : If the patient scores 3 for 1 a – Level of Consciousness, then the following assessments should be
scored as follows :
Assessment # 7 - Score 0 (cannot understand or paralysed)
Assessment # 8 – Score 2
Assessment # 9 – Score 3
Assessment # 11 – Score 2