NIHSS Example

Summary

This video demonstrates the NIH Stroke Scale (NIHSS) assessment process, guiding viewers through each test step while showing how to document results in Medatech. The demonstration includes tests for consciousness, vision, facial symmetry, motor skills, sensation, language, and neglect, with the assessor providing clear examples of scoring and responses. The video emphasizes the importance of performing one test at a time and documenting as you go to ensure accurate stroke assessment and care.

Takeaways

• 😀 The NIH Stroke Scale (NIHSS) is a tool used for assessing stroke severity, and the video demonstrates how to perform this assessment.
• 😀 It is recommended to perform each test one at a time and document as you go, ensuring accuracy throughout the process.
• 😀 The first step of the NIHSS is assessing the patient's level of consciousness by checking responsiveness and awareness.
• 😀 When assessing consciousness with questions, a score of 2 is given if the patient doesn't answer correctly, as seen with Tasha's responses.
• 😀 If a patient is intubated or unresponsive (e.g., aphasia or stupor), they automatically score a 1 or 2 for consciousness assessment.
• 😀 Lateral gaze is assessed by asking the patient to follow a finger with their eyes without moving their head; any neglect in eye movement results in a score of 1.
• 😀 Visual fields are tested by asking the patient to identify numbers with each eye covered. In this case, Tasha performed better with her left eye.
• 😀 Facial drooping is checked by having the patient smile and raise their eyebrows; Tasha had mild facial drooping.
• 😀 Motor assessments of the arms and legs involve asking the patient to hold their limbs in the air for a set time to check for drift or weakness.
• 😀 Coordination and sensation are also assessed, such as having the patient touch their nose and your finger, or checking for sensation differences between limbs.

Q & A

What is the first step in the NIH Stroke Scale (NIHSS) assessment?

The first step is to assess the patient's level of consciousness. This is done by determining whether the patient is awake and able to respond appropriately.

How does the examiner assess a patient's verbal response in the NIHSS?

The examiner asks two questions to assess verbal response: 'Can you tell me your name?' and 'Can you tell me what year it is?' If the patient answers incorrectly, they receive a score based on the number of correct answers.

What is the significance of the score '2' in the NIH Stroke Scale for the level of consciousness?

A score of '2' indicates that the patient cannot stay awake, as observed when Tasha fell back asleep after responding to the examiner's questions.

How is a patient's ability to obey commands assessed in the NIHSS?

The patient is asked to perform simple tasks, such as opening and closing their eyes and fist. If they can follow both commands correctly, they receive a score of '0'.

What does a score of '1' for lateral gaze indicate?

A score of '1' for lateral gaze means that the patient has partial eye movement, where they may neglect to look in one direction, as seen when Tasha could only look to the right and not the left.

How is visual field assessment conducted in the NIHSS?

The examiner asks the patient to cover one eye at a time while the examiner holds up numbers. The patient must correctly identify the number being shown in each visual quadrant.

What does a facial palsy score of '1' indicate?

A score of '1' for facial palsy indicates a mild droop in the patient's facial muscles, which was observed when Tasha had difficulty smiling and raising her eyebrows.

How is the motor function of the arms assessed in the NIHSS?

The examiner asks the patient to raise both arms and hold them up for 10 seconds. The arm that can be held steady scores '0', while the one that drifts down scores a higher number, like '2'.

Why did Tasha receive different scores for her right and left arms during the motor assessment?

Tasha was able to hold her right arm up for the full 10 seconds, so it scored '0'. However, her left arm drifted down, causing it to score '2' for motor function impairment.

What is the purpose of the coordination test in the NIHSS, and how was it assessed in this case?

The coordination test evaluates the patient's ability to perform fine motor skills. In this case, Tasha was asked to run her heel up and down her shin. She struggled with the left leg, scoring '1' for clumsiness.

What does a score of '2' for sensation on the left cheek indicate in the NIHSS?

A score of '2' for sensation means that the patient reported abnormal sensation, in this case, Tasha could not feel the sensation on her left cheek, indicating a sensory deficit.

How is speech and language assessed in the NIHSS, and what did Tasha's results indicate?

Speech and language are assessed using NIH Q-cards, where the patient is asked to describe a picture, name objects, and read sentences. Tasha's results were perfect, as she answered fluently and clearly, scoring '0' for both language and speech.

What does a score of '0' for neglect in the NIHSS mean?

A score of '0' for neglect means that the patient successfully identifies sensations on both sides of their body. Tasha correctly identified the sensations when asked to close her eyes and feel her arms and legs.