Download APEX NIH Stroke Scale Group A Patient 1-6 APEX NIH Stroke Scale Group B Patient 1-6 and more Exams Nursing in PDF only on Docsity! APEX NIH Stroke Scale Group A Patient 1-6 Patient 1 1a- 0 1b- 0 1c- 0 2- 0 3- 0 4- 1 5a- 3 5b- 0 6a- 1 6b- 0 7- 1 8- 2 9- 0 10- 0 11- 1 Patient 2 1a- 0 1b- 2 1c- 0 2- 0 3- 0 4- 1 5a- 0 5b- 0 6a- 0 6b- 0 7- 0 8- 1 9- 2 10- 1 11- 0 patient 3 1a- 0 1b- 0 1c- 0 2- 0 3- 0 4- 1 5a- 0 5b- 0 6a- 2 6b- 2 7- 0 8- 1 9- 0 10- 1 11- 0 Patient 4 1a- 0 1b- 0 1c- 0 2- 0 3- 0 4- 1 5a- 0 5b- 0 6a- 0 6b- 0 7- 0 8- 1 9- 0 10- 0 11- 0 Patient 5 1a- 0 1b- 1 1c- 0 2- 0 3- 2 4- 2 5a- 4 5b- 0 6a- 1 6b- 0 7- 1 8- 1 9- 1 10- 0 11- 1 Patient 6 1a- 0 1b- 0 4- 0 5a- 0 5b- 0 6a- 1 6b- 0 7- 1 8- 1 9- 0 10- 0 11- 1 Patient 6 1a- 0 1b- 0 1c- 0 2- 0 3- 0 4- 0 5a- 0 5b- 0 6a- 0 6b- 1 7- 0 8- 1 9- 0 10- 0 11- 0 NIH Stroke scale (NIHSS) What NIHSS measures measures severity of symptoms of stroke NIHSS areas of assessment Level of consciousness Vision Extraoccular movements Facial Palsy Limb strength Ataxia Sensation Speech and language Grading scale of NIHSS 3 or 4 point scale Scores range from 0-42 Score of >25 Very severe stroke on NIHSS scale Score of 15-24 Severe stroke on NIHSS scale Score of 5-14 Mile to Moderately Severe stroke on NIHSS scale Score of 1-5 Mild stroke on NIHSS scale NIHSS STROKE SCALE common signs of a stroke •Confusion •Slurred speech •Facial droop •Extremity weakness and/or numbness •Vision disturbance •Dysphasia •Ataxia FAST •FAST - rapid identification for lay people •Does not identify sensory impairment, vertigo or gait changes -Facial droop -Arm weakness -Slurred speech -Time ways to assess a stroke •FAST - rapid identification for lay people •CPSS, LAPSS, ROSIER - used for prehospital and ER recognition •NIHSS NIHSS (National Institutes of Health Stroke Scale) •Reliable and valid •Used to objectively quantify the stroke impairments •Also used in emergent situations to determine treatment planning (the need for tPA) in the 3 - 4.5 hour window, along with clinical decision making •Predictor of short and long-term outcomes •Does not capture all stroke symptoms - vertebrobasilar stroke can cause vertigo, nausea and vomiting, headache, oculomotor signs 1. Level of Consciousness 2. Best Gaze 3. Visual Fields 4. Facial Paresis 5. Motor Arm 6. Motor Leg 7. Limb Ataxia 8. Sensory 9. Best Language 10. Speech 11. Extinction and Inattention 1-11 of the NIHSS Level of Consciousness Divided into 3 sections: •Responsiveness •Questions •Commands 0 = alert; responsive 1 = not alert; arousable by verbal or minor stimuli to respond 2 = not alert; arousable by repeated or strong or painful stimuli to respond; obtunded 3 = unresponsive; only reflexive motor or autonomic movement; unresponsive, flaccid 1a. LOC Responsiveness (scaled 0-3) •Ask what the month is •Ask what the patient age is (not birth year!) ◦ 0 = both correct ◦ 1 = one wrong ◦ 2 = two wrong •NO PARTIAL CREDIT - patient is either right or wrong. Only accept the first answer, make sure no one is helping •Patients unable to speak can write the answer •If they are unresponsive, stuporous and unable to understand the questions or aphasic