Welcome to this demonstration of the National Institutes of Health Stroke Scale, also known as the NIH Stroke Scale. The NIH Stroke Scale remains the stroke severity rating scale of choice for the American Heart Association and American Stroke Association. The 15-item NIH Stroke Scale is a standard stroke scale for all of the United States.
quantifies the degree of neurological deficit and facilitates communication. It also helps identify patients who may qualify for emergent treatment, allows objective measurement of changing clinical status, and identifies those at higher risk for complications. Medical professionals who use the NIH Stroke Scale tool infrequently may find it challenging to administer.
During this video, we will demonstrate how to accurately perform NIH Stroke Scale scoring. The scale runs from 0, for no functioning deficits, to 42, for very severe functioning deficits. Keep in mind, the NIH Stroke Scale tool was originally designed by a physician that liked to play golf, so if you find it helpful, a low score is better than a high score.
Before beginning the NIH Stroke Scale assessment, identify any factors that may cause inaccuracies in scoring. This could include the use of sedating medications, alcohol or drug intoxication, Physical disability due to a previous injury, past stroke, or other causes. Factors such as these should be documented and also verbally communicated to fellow providers involved in the patient's care.
The first item assessed on the NIH Stroke Scale is level of consciousness. When you enter the room and find your patient is alert to their surroundings, they score a zero. If they are drowsy but can arouse and stay awake long enough to do the exam, they score a one.
Are you awake? However, if they keep falling asleep to the point where you can't finish the exam, they score a 2. Can you open your eyes? If you can't get them to wake up and respond to you in a purposeful manner, they score a 3. Can you open your eyes?
Can you open your eyes? Open your eyes! We further test level of consciousness by asking two questions.
First, ask your patient, what month is it? And then ask your patient, what is your age? At this point, we are testing the brain to see how well it is processing information.
We are not yet testing speech or language. That will come later. If your patient gets both answers correct, they score a zero. Can you tell me what month it is? August.
And what is your age? 42. If they get one correct, they score a one. What month is it?
August. It is August. What is your age?
If they get neither correct, they score a 2. What month is it? Uh, December? No, it's August.
What is your age? 20, 21. If a patient can't speak, have them write down their answers. Or, hold up the correct number of fingers for their age. They also can pick the correct month from a written list you provide them. If they can nod to the correct choice, you'll know they are processing information accurately.
Finally, we test level of consciousness by having the patient follow two commands. First, ask them to close their eyes and then open them. Next, instruct the patient to open and then close their fist. If your patient cannot perform this command due to amputation or immobilization by stroke, give them a command they are physically able to do, such as moving a foot. Also, if the patient does not follow a command verbally, the action should be demonstrated, as they may be suffering from receptive aphasia.
More to come on that later. Close your eyes and then open them. Open your hand and make a fist.
They should then be given another opportunity to perform the command and the result scored accordingly. Remember, this isn't about testing language or strength. It is seeing if the patient can process information and follow a command. If they follow both commands, they score a good score. or a zero.
Open and close your eyes. I want you to open your fist and close it. If they can only follow one command, they score a one. Close your eyes and then open them. And open up your hand and make a fist.
And if they can't perform either command, they score a 2. Open your eyes. And close your eyes. Can you open your hand and make a fist? Next, we are going to test the patient's lateral gaze. Lateral gaze evaluates the eye's ability to move horizontally to the left and right.
Patients may have difficulty following lateral gaze instructions and attempt to move their face left to right. Therefore, it is recommended to gently hold their chin steady while you have them use only their eyes to follow your fingers from side to side across their horizontal view. If they can follow your finger all the way to the left and all the way to the right, they score a zero.
If they can only follow your finger to one side, they score a one. For example, If they can look to the left but cannot cross midline and follow to the right, score a 1. This is known as partial gaze deviation. A patient with a gaze that is fixed to the left or right, even if you move their head gently from side to side for them, will score a 2. This is known as forced gaze deviation. Testing lateral gaze in confused or uncooperative patients can sometimes be challenging. If so, gently move the patient's head from side to side.
The normal response is to try and keep the examiner in view, allowing you to see if the patient moves their eyes to the left, midline, and to the right. The visual field test is next. With this, we are looking for partial or total vision loss.
A visual field can be defined as the entire area that can be seen when an eye is fixed on a central point. The visual field can be divided into four quadrants, upper left, lower left, upper right, and lower right. Both eyes must be tested separately.
To ensure accuracy when testing visual fields, the provider should stand 1 to 2 feet in front of the patient. Position your hands within the patient's field of vision, ideally no further apart than the width of the patient's shoulders. With the patient looking straight ahead, have them cover one eye at a time and answer, Yes, or point when they see your fingers wiggling. Remember, you want to test the visual field of each eye. Patients that can see in all four quadrants of both eyes score a zero.
A patient that can't see in one visual quadrant on one side will score a one. Patients that can't see in both the upper and lower quadrants of one side will score a two. Patients that are blind in all four visual quadrants of both eyes score a 3. Up next is the test for facial weakness, otherwise known as facial palsy. When testing for facial weakness, have the patient smile or ask them to show you their teeth, raise their eyebrows, and then close their eyes tight while you gently pull up on their eyelids.
If upper and lower facial features are symmetrical, they score a zero. If you see a mild droop of the mouth, they score a one. If they have an obvious facial droop at rest, they score a two.
If you are finding both upper and lower weakness, such as a droopy mouth and a droopy eye, or they can't wrinkle their brow, they score a three. With some patients, a droopy eye is obvious, but on others, you won't pick up on this until you have the patients close their eyes tight while you gently pull up on the eyelids and then find that one eye can't stay closed. All right, now it's time to test your patient for arm weakness.
If the patient is sitting in a chair, have them close their eyes and hold their arms straight out in front of them at a 90-degree angle from their body. If the patient's eyes remain open for this portion, they may be able to compensate for an arm drift. If the patient is lying in bed, have the patient Hold their arms out at a 45 degree angle.
It is all about having gravity pull on the arms when you are testing for weakness. Have the patient hold their arms in place for a count of 10 seconds. Each arm is given a separate score, but should be tested together. If the patient can hold their arms relatively steady, they score a zero.
Remember, we all have a little wobble when we do this. However, if one arm tries to drift down, the patient scores a one. And if one arm drifts down and touches the bed, they score a 2. If one of the patient's arms drops to the bed or they can't lift it, but they have some side-to-side or gripping movement or can wiggle their fingers in that arm, they score a 3. They score a 4 if one arm drops to the bed and has no movement at all, even to stimulation. For anyone that has had an amputation of the shoulder or fusion of the arm, we document UN for untestable. The next step is to test your patient for leg weakness.
This is very similar to testing for arm weakness, however you will test each leg separately. Instruct the patient to hold their leg straight out for a count of 5 seconds if they are sitting in a chair. If your patient is lying down, have them hold their leg at a 30 degree angle from the bed for a count of 5 seconds.
Again, testing each leg separately. The scoring for leg weakness is the same as scoring for the arm. Holding the leg steady scores a 0. If the leg drifts down but does not hit the bed or other surface, score a 1. If the leg drifts down and touches the bed or other surface, score a 2. If the patient's leg drops to the bed or they are unable to move it, but it has some side-to-side movement, score a 3. Again, no movement at all will score a 4. For a patient with an amputation or fusion of the leg, just as in the arm, document UN for untestable. Test and score your patient's limb coordination next. With this test, it is important to differentiate in coordination from weakness.
To assess arm coordination, we perform a finger-nose-finger test. First, have the patient touch their nose and then touch your finger to assess their arm length. We then move our finger back slightly and ask the patient to touch your finger.
and back to their nose again. Repeat this a few times. Each arm is tested separately.
An abnormal finding would be clumsy, uncoordinated movements in one or both arms. To assess leg coordination, we perform a heel-shin test. Have the patient take the heel of their foot and run it up and down the shin of the opposite leg. You will need to test each leg separately. If the patient is able to perform bilateral finger-nose-finger test and bilateral heel-shin test without clumsiness, they score a 0. If your patient is clumsy in one limb, score a 1. If your patient is clumsy in two limbs, score a 2. Again, each limb is tested separately.
We have found that examiners often misscore the coordination test. You can't expect a patient to have good coordination when they can't lift their arm or leg. Therefore, if the patient is unable to perform the test for any reason, such as fusion, weakness, or amputation, mark them UN for untestable.
The next step is to test sensation. You will compare one side of your patient's body to the other. It is recommended to break a cotton-tipped applicator in half and use the non-cotton-tipped end to perform the exam.
It is important to use bare skin for this test. Show the patient what you are going to do and demonstrate how it is going to feel before you ask them to close their eyes for this testing. Test the cheeks, forearms, thighs, and shins while having the patient compare one side of their body to the other as you move through the testing. If both sides feel the same, score a zero.
If one side feels dull compared to the other, Score a 1. Can you feel me touching you? Yes. Where at?
Left. About now? Yes. What side? Right.
Does it feel the same on both sides? Feels duller on the right. Okay.
If the patient can't feel anything on one side to stimulation, score a 2. Can you feel me touching you? Yes. Where? On the right. Can you feel me touching you?
I don't feel anything. Next up is an assessment of the patient's ability to produce and comprehend language. Language dysfunction is known as aphasia.
There are two types of aphasia. Expressive aphasia, expressive aphasia, and receptive aphasia. Patients experiencing expressive aphasia will have partial or complete loss of the ability to produce language, either spoken, manual, or written.
With expressive aphasia, language comprehension generally remains intact. Patients with receptive aphasia will have difficulty understanding written or spoken language. but are able to produce language appropriately. Keep in mind that individuals experiencing receptive aphasia may require pantomime demonstrations to complete other portions of the NIH Stroke Scale, since they may not understand verbal commands.
You can test patients who have some function of speech as well as partially assess those who cannot speak due to being intubated by having them write their answers to your test questions. You can also test your blind patient's speech and language communication abilities by having them name objects you give them to hold. First, we assess if the patient can comprehend and use speech. Can you understand them and can they understand you?
You'll do this by having the patient describe and name some pictures. I see two young children getting cookies out of a cookie jar with a stool that's going to fall. If correct, full sentences are used. The patient scores a zero. Covers your hand, you know.
If wrong or incomplete sentences are used, but they get the message across, they score a one. Oh boy. If the patient is incomprehensible, or what they say does not make sense, they score a 2. Can you name this object?
If the patient can't speak or properly communicate with you through writing or nodding yes or no, they score a 3. Next, we assess for dysarthria. This is dysfunction of speech articulation due to motor weakness of speech-generating muscles of the tongue, lips, and or the face. If the patient says the correct words but they are slurred, dysarthria should be suspected. To test for this, have the patient read or repeat sentences shown or spoken to them.
Down to earth. I got home from work. If the patient has no slurring of their speech, they score a zero.
Down to earth. I got home for work. If they slur, but you can still understand them, they score a one.
Can you say mama? Mama. If they slur and you can't understand them or they can't speak at all, score a 2. If they are intubated, document UN for untestable because you can't score the patient.
The speech-language test of the NIH Stroke Scale is another place where examiners have a tendency to misscore patients. Think of language as the ability to communicate and comprehend words, either spoken or written. This is different from the motor function of speech.
which is the ability to move your mouth and use your tongue to speak clearly. And now we come to the last element of the NIH Stroke Scale. This is testing for visual and or sensory neglect or inattention of one side of the body. To do this, you must first test both sides of the visual field at the same time.
Then, you must test the patient's sensation on both sides of the body at the same time. Some patients may only have visual field neglect. Others, only sensory neglect.
Some patients may have both sensory and visual neglect. To test both sides of the visual field together, have the patient look straight at you. Using both your hands, wiggle your fingers and ask the patient if they are seeing movement on the right side, left side, or both sides. Make sure to test both upper and lower visual quadrants.
For sensation, have the patient close their eyes. Touch the patient on both sides of the face, forearms, thighs, and shins, asking if they are feeling your touch and where they are feeling it. Alternate from testing right, left, and both during this exam.
Remember to test and compare bare skin. If a patient can feel and see both sides when stimulated together, score is zero. If you are unable to test neglect or inattention due to complete vision loss, for example, or if the patient is unable to communicate which side is being touched, also score is zero. A patient that can't see or can't feel one side of their body when tested at once, score a one. Right, left, left.
A patient that can't see and cannot feel one side of their body when tested at the same time, score a 2. The most profound type of neglect is sensory-visual neglect. Your patient may keep trying to push their own arm or leg out of the bed because they think someone else is in the bed with them. More often, we encounter patients that can see on both sides of their body or can feel on both sides of their body until both sides are stimulated at once. The neglected side gets no input and they can't see or feel on that side.
A few final thoughts and suggestions for when you are performing the NIH Stroke Scale. At times, your stroke patient will need guidance in completing a portion of the exam. Try not to coach them in their responses and accept their first effort to ensure an accurate result.
Do not go back and change scores. Scores should reflect what the patient does and not what the clinician thinks the patient can do. Also, keep in mind that individuals with a low score may still have a life-altering disability.
The disability should be considered when a treating provider makes decisions regarding treatment. For example, if the only deficit noted during the NIH Stroke Scale is right arm weakness, the patient's total score could be as low as a 1 or a 2. However, this disability would be devastating for a patient whose career depends on using their hands. such as an artist or a truck driver. Finally, there is a lot of valuable information you will learn while completing the NIH Stroke Scale that will enable you to better care for your stroke patients and keep them safe from future injury.
With that, we conclude this demonstration of the NIH Stroke Scale. On behalf of the American Heart Association and North Dakota Department of Health EMS Division, I'd like to thank you for your time, and for the work you do in providing quality stroke care.