NIH Stroke Scale Group B Patient 1-6, NIH Stroke Scale, Exams of Nursing

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NIH Stroke Scale

• Patient 1 - correct answer1a-
• 1b-
• 1c-
• 2 -
• 3 -
• 4 -
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• 6a-
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• Patient 2 - correct answer1a-
• 1b-
• 1c-
• 2 -
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• 4 -
• 5a-
• 5b-
• 6a-
• 6b-
• 7 -
• 8 - NIH Stroke Scale
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• patient 3 - correct answer1a-
• 1b-
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• 2 -
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• 4 -
• 5a-
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• Patient 4 - correct answer1a-
• 1b-
• 1c-
• 2 -
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• 4 -
• 5a-
• 5b- NIH Stroke Scale
• 6a-
• 6b-
• 7 -
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• Patient 5 - correct answer1a-
• 1b-
• 1c-
• 2 -
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• 6a-
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• 7 -
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• Patient 6 - correct answer1a-
• 1b-
• 1c-

NIH Stroke Scale

2 - 0

3 - 0

4 - 0

5a- 0 5b- 0 6a- 0 6b- 1 7 - 0 8 - 1 9 - 0 10 - 0 11 - 0 1A - Level of consciousness - correct answer0 - Alert; keenly responsive 1 - Arouses to minor stimulation 2 - Requires repeated stimulation to arouse 2 - Movements to pain 3 - Postures or unresponsive 1B - Ask month and age - correct answer0 - Both questions right 1 - One question right 1 - Dysarthric, intubated, trauma, or language barrier 2 - Aphasic 1C - "Blink eyes" and "Squeeze hands" - correct answer0 - Performs both tasks 1 - Performs one task 2 - Performs neither task 2 - Test horizontal extraocular muscles - correct answer0 - Normal 1 - Partial gaze palsy: can be overcome

NIH Stroke Scale

1 - Partial gaze palsy: corrects with oculocephalic reflex 2 - Forced gaze palsy: can not be overcome 3 - Test visual fields - correct answer0 - No visual loss 1 - Partial hemianopia 2 - Complete hemianopia 3 - Patient is bilaterally blind 3 - Bilateral hemianopia 4 - Test facial palsy (use grimace if obtunded) - correct answer0 - Normal symmetry 1 - Minor paralysis (flat nasolabial fold, asymmetric smile) 2 - Partial paralysis (lower face) 3 - Unilateral complete paralysis (upper/lower face) 3 - Bilateral complete paralysis 5A - Test left arm motor drift - correct answer0 - No drift for 10 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 5B - Test right arm motor drift - correct answer0 - No drift for 10 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion

NIH Stroke Scale

6A - Test left leg motor drift - correct answer0 - No drift for 5 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 6B - Test right leg motor drift - correct answer0 - No drift for 5 seconds 1 - Drift, but doesn't hit bed 2 - Driift, hits bed 2 - Some effort against gravity 3 - No effort against gravity 4 - No movement 0 - Amputation/joint fusion 7 - Test limb ataxia (Finger-nose, heel-shin) - correct answer0 - No ataxia 1 - Ataxia in 1 limb 2 - Ataxia in 2 limbs 0 - Doesn't understand, paralyzed, amputation 8 - Test sensation - correct answer0 - Normal 1 - Mild-moderate loss: less sharp/more dull 1 - Mild-moderate loss: can sense being touched 2 - Complete loss: cannot sense being touched 2 - No response and quadriplegic 2 - Coma, unresponsive 9 - Test language/aphasia (Describe the scene, name words, read the sentences) - correct answer0 - Normal; no aphasia

NIH Stroke Scale

1 - Mild-moderate aphasia: some obvious changes without significant limitation 2 - Severe aphasia: fragmentary expression, interference needed, cannot identify materials 3 - Mute/global aphasia: no usable speech/auditory comprehension 3 - Coma, unresponsive 10 Test dysarthria (read words: Mama, Tip-top, Fifty-fifty, Thanks, Huckleberry, Baseball player)

• correct answer0 - Normal; no dysarthria 1 - Mild-moderate dysarthria: slurring but can be understood 2 - Severe dysarthria: unintelligible slurring or out of proportion to dysphasia 2 - Mute/anarthric 0 - Intubated/unable to test 11 - Test extinction/inattention - correct answer0 - No abnormality 1 - Visual/tactile/auditory/spatial/personal inattention 1 - Extinction to bilateral simultaneous stimulation 2 - Profound hemi-inattention (does not recognize own hand) 2 - Extinction to > 1 modality What NIHSS measures - correct answermeasures severity of symptoms of stroke NIHSS areas of assessment - correct answerLevel of consciousness Vision Extraoccular movements Facial Palsy Limb strength Ataxia Sensation Speech and language Grading scale of NIHSS - correct answer3 or 4 point scale Scores range from 0- 42

NIH Stroke Scale

Score of >25 - correct answerVery severe stroke on NIHSS scale Score of 15- 24 - correct answerSevere stroke on NIHSS scale Score of 5- 14 - correct answerMild to Moderately Severe stroke on NIHSS scale Score of 1- 5 - correct answerMild stroke on NIHSS scale