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NIHSS
NIH
| Question | Answer |
|---|---|
| Level of consciousness 1A NIHSS | 0=Alert and keenly responsive, 1=Not alert; arousable with minor verbal stimuli, 2=Not alert; requires vigorous, painful or strong stimulation, 3=Reflexive postural movements only to repeated stimuli. 3 is only when they make no movement except reflexive |
| LOC 1A | 3 score should be assessed by sternal rub. Generally in a coma |
| a coma | Coma is the prolonged period of unconsciousness immediately following traumatic brain injury. In this sleep-like state, there is no speech, the eyelids are usually closed, and there is no response to commands. |
| Glascow Coma Scale | Glasgow Coma Scale is the standard measurement of coma in the acute phase. |
| Medically induced coma | initiated by anesthesiologist (barbiturate given then proposal). Used to reduce intracranial pressure. |
| Normal state of consciousness | Defined as either wakefulness, alertness or awareness most humans experience when not asleep. |
| Abnormal state of consciousness | any LOC that deviates from the normal state of consciousness (awareness most people experience when awake). |
| Clouding of consciousness | a very mild form of altered mental status in which the patient has inattention and reduction of wakefulness. |
| Clouding of consciousness cont. | A disturbance of consciousness in which a patient cannot think clearly and has difficulty paying attention to what is happening or what is being said. Mild and less severe than a delirium. Brain fog or mental fog |
| Delirium/ Acute confusional state | Generally reversible. Onset ranges from hours to several days. Results in a decreased awareness of one's environment and confused thinking. |
| Confusional state | Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands. |
| Lethargy/ Somnolence | Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep. |
| Somnolence /Drowsiness /sleepiness | Somnolence (alternatively "sleepiness" or "drowsiness") is a state of strong desire for sleep, or sleeping for unusually long periods (cf. hypersomnia). |
| Obtundation | Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states. |
| Stuporous | Stupor means that only vigorous and repeated stimuli will arouse th e individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state. |
| Coma | Coma is a state of unarousable unresponsiveness |
| 1A | the observers overall impression of the patient's alertness |
| 1B level of consciousness questions NIHSS | Ask Month and year, Ask patients age. (no partial credit. score the first answer.) |
| 1B continued | 0= answers both correctly. 1=answers only one correctly (patients with severe dysarthria or ET tube in place automatically scores a 1). 2=answers neither question correctly. |
| 1B contiued score of 2 | Patients that scored a 3 on LOC 1A must score a 2 on LOC 1B. |
| 1C commands NIHSS | Ask to perform two tasks. 1)close eyes, now open. 2)make a fist with your hand, now open (score lowest to prove reproducabiity). |
| Scoring 1C | 0=performs both. 1=performs one 2=neither task completed correctly. (score what you witness and not what you think). Score 1 if they attempt to but can't cause of weakness. Score 2 if theres a defecit in which the patient has difficulty following |
| 1c if the patient is amputated | if there is an amputation substitute another onestep command. |
| 2 best gaze NIHSS | Tests voluntary eye movements. 1)Look at eyes at rest. Look for spontaneous movements 2)move finger or object horizontally and have patient follow the target without moving the head. If the patient cannot follow, a stronger test is needed. |
| scoring 2 | 0=normal, 1=partial gaze palsy, 2= patient has tonic deviation and the eyes cannot be moved. total palsy |
| 2 best gaze, may use ocular cephalic reflex assessment | have patient look at one spot, turn head to left quickly, eyes should move to the right to keep on the focused object, repeat by turning head left and right. |
| nystagmus | rapid involuntary movements of the eye. |
| gaze palsy | paralasys of the eye, noted when assessing 2 on the NIHSS. Partial gaze noted when assessing oculo cephalic reflex. A crossing of the eyes will be noted. |
| causes of palsy | HTN, DM, trauma |
| ptosis | Drooping of the eye. Usually caused by damage to a cranial nerve. |
| 3 Visual fields NIHSS | Assess each eye independently. Have patient look directly at you and assess their peripheral vision by covering the untested eye and asking them to identify how many fingers you have up. |
| Scoring 3 visual fields | 0=if upper and lower visual fields are normal.Even if patient has obvious defect in other eye but one works fine give 0. 1=if a clearcut asymmetry/partial hemianopia. 2=complete hemianopia |
| hemianopia | Blindness on half of the visual field. Usually on one side of the vertical midline. |
| complete hemianopia | Person can only see one side when looking straight ahead. |
| partial hemianopia | Objects appear different in color and brightness. Sometimes may have double vision. |
| NIH assessing 3 on LOC 3 | Assess by visual threat if a patient scored a 3 on the LOC 1A |
| 4 facial palsy NIHSS | 1)show me your teeth/gums 2)Close eyes tightly and open 3)raise your eyebrows. In a patient that cannot follow commands use a noxious stimulus and assess the symmetry in their grimace. Remember to remove tape and dressings that may obscure the face. |
| Scoring 4 | 0=normal symmetrical movement 1=minor paralysis (includes minor asymmetry when smiling) 2=partial paralysis (paralysis of lower face) 3=complete paralysis (of upper and lower face) also appropriate for obtunded and comatose patients. |
| tips for assessing NIH 4 | 1) determine if normal. If not determine if asymmetry of smile. if not, |
| 5 motor arms NIHSS | If patient sitting, extend arms 90degrees. If supine extend 45 degrees. Drift is scored if arm falls within 10 seconds. Do not test limbs simultaneously. Have palms facing down. |
| Scoring 5 NIH | 5a-left, 5b-right. 0=normal, no drift. arm remains in position for 10 seconds. 1=after initial dip, when letting go of arm, arm drifts downward. 2= some effort against gravity but arm cannot maintain. 3=no effort against gravity 4=no movement at all. |
| NIH assessing 5 on LOC 3 | Patients scored 4 on this item if a 3 on 1A. |
| 5 difference between 3 and 4 | if any movement (shoulder shrug) give a 3. If comatose of stuporous give a 4. |
| 6 motor legs NIHSS | Assess with patient lying supine. Raise each leg 30 degrees to assess. Begin counting immediately after release of the limb. |
| 5 and 6 on NIHSS | dont score if there is fusion of shoulder of hip joint. Or total amputation. |
| Ataxia | loss of full control of bodily movement |
| 7 ataxia on NIHSS | finger, nose, finger and heel shin test on both right and left sides. Move your finger as you ask the patient to touch your finger from their nose. |
| Scoring ataxia 7 on NIH | 0=absent. smooth accurate and not clumsy. Absent in patients unable to perform. 1= in ataxia present in one limb. 2=present in two limbs. |
| 7 for patients with 3 on LOC | give a 0 for a comatose of stuporous patient unless ataxia is present. |
| 8 sensory perception on NIHSS | Assess by pinpointing. Ask to compare both sides for symmetry or more pain on one side. Assess for grimacing on both sides if the patient is aphasic. Do not test through clothing. Start with face, then arms, then legs. |
| Scoring sensory 8 on NIH | 0=Normal, no sensory loss, 1=mild to moderate sensory loss, 2=Severe or total sensory loss. (total loss must be obvious. Apply nail bed pressure if pins aren't felt). |
| 8 on patients with 3 on LOC | Automatic 2 on this item. |
| 9 language on NIHSS | Listen for this item throughout the entire assessment up to this point. Get cookie jar picture and sentence card. Assessment based on their overall answers. |
| Scoring language 9 on NIH | 0=no aphasia. 1=mild to moderate aphasia evident by expression. No change in comprehension. 2=severe aphasia (cannot identify card comments. All words are fragmented) 3=mute or global aphasia |
| 10 dysarthria | |
| scoring dysarthria 10 on NIH | 0=Normal read all words w/o slurring, 1=mild to moderate speech slurring, speech understood, 2= severe slurring (lack of speech or incomprehension.) Untestible if intubated |
| 10 on patients with 3 on LOC | Automatic 2 |
| 11 extinction and inattention on NIHSS | Ask patient to close eyes then touch one side at a time assessing for patient's sensation. Then touch both sides and see if they feel both. Start with face, then arms, then legs. |
| Scoring of extinction and inattention on NIH | 0=Normal, 1=visual, tactile, auditory, or personal inattention. 2=profound hemi-inattention or extinction to more than one modality. |
Created by:
Nana0904