Nih Stroke Scale Test A Answers

The National Institutes of Health Stroke Scale (NIHSS) is a systematic assessment tool used by healthcare professionals to evaluate the neurological status of patients who have experienced a stroke. It is a standardized, multi-item examination that quantifies stroke-related neurological deficits. The NIHSS is widely used in clinical practice and research to assess stroke severity, monitor changes in neurological status over time, and predict patient outcomes. This comprehensive article will delve into the intricacies of the NIHSS, providing a detailed guide to understanding and interpreting the scale.

Introduction to the NIH Stroke Scale

A stroke, often referred to as a "brain attack," occurs when blood supply to the brain is interrupted, leading to cell damage and neurological deficits. Rapid assessment and intervention are crucial to minimize brain damage and improve patient outcomes. The NIHSS plays a pivotal role in this process by providing a standardized method for evaluating the severity of a stroke.

The NIHSS is a 15-item neurological examination that assesses various aspects of brain function, including:

• Level of consciousness: Alertness and responsiveness.
• Visual fields: Ability to see in all visual fields.
• Extraocular movements: Eye movements and presence of gaze palsy.
• Facial palsy: Weakness or paralysis of facial muscles.
• Motor function: Strength in the arms and legs.
• Limb ataxia: Coordination and balance.
• Sensory function: Ability to feel touch and pain.
• Language: Speech and comprehension.
• Dysarthria: Clarity of speech.
• Extinction and inattention: Awareness of stimuli on both sides of the body.

Each item on the NIHSS is scored on a scale ranging from 0 to 4 or 0 to 3, with higher scores indicating more severe impairment. The total NIHSS score ranges from 0 to 42, with 0 indicating no stroke-related deficits and 42 indicating severe impairment.

Detailed Breakdown of NIHSS Items and Answers

Each component of the NIHSS is designed to assess specific neurological functions affected by stroke. Accurate administration and scoring of each item are essential for reliable and valid results. Let's examine each item in detail:

1A. Level of Consciousness (LOC)

This item evaluates the patient's overall alertness and responsiveness. The scoring is as follows:

• 0 = Alert: The patient is fully alert and responsive to stimuli.
• 1 = Drowsy: The patient is not fully alert but can be aroused by minor stimulation.
• 2 = Stupor: The patient requires repeated stimulation to maintain attention or is obtunded and requires strong or painful stimuli to elicit a response.
• 3 = Coma: The patient is unresponsive, even to painful stimuli.

Key Considerations:

• Assess the patient's baseline level of consciousness before the stroke, if possible.
• Document the type and intensity of stimulation required to elicit a response.
• If the patient is intubated or has a language barrier, rely on observation of their responses to stimuli.

1B. LOC Questions

This item assesses the patient's ability to answer two simple questions correctly: "What month is it?" and "How old are you?" The scoring is as follows:

• 0 = Answers both questions correctly: The patient provides accurate answers to both questions.
• 1 = Answers one question correctly: The patient answers one question correctly.
• 2 = Answers neither question correctly: The patient does not answer either question correctly.

Key Considerations:

• If the patient is unable to speak due to intubation or aphasia, score based on the best available evidence, such as gestures or written responses.
• Allow the patient a reasonable amount of time to respond to each question.
• If the patient's answer is close but not entirely accurate, use clinical judgment to determine whether to score it as correct.

1C. LOC Commands

This item assesses the patient's ability to follow two simple commands: "Close your eyes" and "Make a fist." The scoring is as follows:

• 0 = Performs both tasks correctly: The patient performs both commands correctly.
• 1 = Performs one task correctly: The patient performs one command correctly.
• 2 = Performs neither task correctly: The patient does not perform either command correctly.

Key Considerations:

• Give the commands clearly and one at a time.
• If the patient has a motor deficit that prevents them from performing a command, score based on their attempt to follow the command.
• If the patient is unable to understand the commands due to language barriers, use gestures to demonstrate the commands.

2. Best Gaze

This item assesses the patient's ability to move their eyes horizontally. The scoring is as follows:

• 0 = Normal: The patient has normal horizontal eye movements.
• 1 = Partial gaze palsy: The patient has partial gaze palsy, meaning they have difficulty moving one or both eyes in one direction.
• 2 = Forced deviation: The patient has forced deviation of the eyes, meaning their eyes are involuntarily fixed in one direction.

Key Considerations:

• Assess the patient's ability to follow a moving target, such as a finger or pen.
• If the patient has a pre-existing gaze palsy, score based on the change from their baseline.
• If the patient is unable to cooperate with the examination due to decreased level of consciousness, score based on observation of their spontaneous eye movements.

3. Visual Fields

This item assesses the patient's ability to see in all visual fields. The scoring is as follows:

• 0 = No visual loss: The patient has no visual loss.
• 1 = Partial hemianopia: The patient has partial loss of vision in one half of the visual field in one or both eyes (hemianopia).
• 2 = Complete hemianopia: The patient has complete loss of vision in one half of the visual field in one or both eyes.
• 3 = Bilateral hemianopia (blindness): The patient is blind due to bilateral hemianopia.

Key Considerations:

• Assess visual fields by confrontation, comparing the patient's visual fields to your own.
• If the patient has decreased level of consciousness, assess visual fields by observing their response to visual stimuli presented in different areas of the visual field.
• If the patient has a pre-existing visual field deficit, score based on the change from their baseline.

4. Facial Palsy

This item assesses the patient's facial symmetry and strength. The scoring is as follows:

• 0 = Normal: The patient has normal facial symmetry and strength.
• 1 = Minor paralysis: The patient has minor facial weakness or asymmetry, such as flattening of the nasolabial fold.
• 2 = Partial paralysis: The patient has partial paralysis of the face, such as drooping of one side of the mouth.
• 3 = Complete paralysis: The patient has complete paralysis of one side of the face.

Key Considerations:

• Ask the patient to smile, frown, and raise their eyebrows to assess facial movement.
• Observe the patient's facial expression at rest to assess for asymmetry.
• If the patient has decreased level of consciousness, observe their facial movements during spontaneous expressions.

5. Motor Arm (Left and Right)

This item assesses the strength of the patient's arms. Each arm is assessed separately. The scoring is as follows:

• 0 = No drift: The patient holds the arm outstretched for 10 seconds without drifting downward.
• 1 = Drift: The patient's arm drifts downward before the full 10 seconds, but they do not hit the bed.
• 2 = Some effort against gravity: The patient is able to move the arm against gravity but cannot hold it outstretched for the full 10 seconds.
• 3 = No effort against gravity: The patient is unable to move the arm against gravity.
• 4 = No movement: The patient has no movement in the arm.
• 9 = Amputation or joint fusion: The patient has an amputation or joint fusion that prevents assessment of arm strength.

Key Considerations:

• Assess each arm separately.
• Position the patient supine with their arms outstretched at a 90-degree angle.
• Encourage the patient to keep their eyes closed during the assessment.
• If the patient has pain or other limitations that prevent them from fully extending their arm, document the reason and score accordingly.

6. Motor Leg (Left and Right)

This item assesses the strength of the patient's legs. Each leg is assessed separately. The scoring is as follows:

• 0 = No drift: The patient holds the leg outstretched for 5 seconds without drifting downward.
• 1 = Drift: The patient's leg drifts downward before the full 5 seconds, but they do not hit the bed.
• 2 = Some effort against gravity: The patient is able to move the leg against gravity but cannot hold it outstretched for the full 5 seconds.
• 3 = No effort against gravity: The patient is unable to move the leg against gravity.
• 4 = No movement: The patient has no movement in the leg.
• 9 = Amputation or joint fusion: The patient has an amputation or joint fusion that prevents assessment of leg strength.

Key Considerations:

• Assess each leg separately.
• Position the patient supine with their legs raised at a 30-degree angle.
• Encourage the patient to keep their eyes closed during the assessment.
• If the patient has pain or other limitations that prevent them from fully extending their leg, document the reason and score accordingly.

7. Limb Ataxia

This item assesses the patient's coordination and balance in the limbs. The scoring is as follows:

• 0 = Absent: The patient has no ataxia.
• 1 = Present in one limb: The patient has ataxia in one limb.
• 2 = Present in two limbs: The patient has ataxia in two limbs.

Key Considerations:

• Assess ataxia by asking the patient to perform finger-to-nose and heel-to-shin tests.
• If the patient has weakness that prevents them from performing these tests, score based on observation of their attempted movements.
• If the patient has decreased level of consciousness, assess ataxia by observing their spontaneous movements.

8. Sensory

This item assesses the patient's ability to feel touch and pain. The scoring is as follows:

• 0 = Normal: The patient has normal sensation.
• 1 = Mild to moderate sensory loss: The patient has mild to moderate sensory loss, but is aware of being touched.
• 2 = Severe to total sensory loss: The patient has severe to total sensory loss and is not aware of being touched.

Key Considerations:

• Assess sensation by lightly touching the patient's face, arms, and legs with a cotton swab or pinprick.
• Compare sensation on both sides of the body.
• If the patient has decreased level of consciousness, assess sensation by observing their response to noxious stimuli.

9. Best Language

This item assesses the patient's ability to speak and understand language. The scoring is as follows:

• 0 = No aphasia: The patient has no difficulty speaking or understanding language.
• 1 = Mild to moderate aphasia: The patient has mild to moderate difficulty speaking or understanding language, but can still communicate.
• 2 = Severe aphasia: The patient has severe difficulty speaking or understanding language and cannot communicate effectively.
• 3 = Mute, global aphasia: The patient is mute or has global aphasia, meaning they have complete loss of language function.

Key Considerations:

• Assess language by asking the patient to name objects, repeat phrases, and follow commands.
• If the patient has decreased level of consciousness, assess language by observing their response to spoken commands.
• If the patient has a pre-existing language impairment, score based on the change from their baseline.

10. Dysarthria

This item assesses the patient's clarity of speech. The scoring is as follows:

• 0 = Normal: The patient's speech is clear and easy to understand.
• 1 = Mild to moderate dysarthria: The patient's speech is mildly to moderately slurred, but still understandable.
• 2 = Severe dysarthria: The patient's speech is severely slurred and difficult to understand.

Key Considerations:

• Assess dysarthria by asking the patient to read a standardized passage or repeat phrases.
• Listen for changes in the patient's voice quality, articulation, and rhythm.
• If the patient has decreased level of consciousness, assess dysarthria by listening to their spontaneous speech.

11. Extinction and Inattention

This item assesses the patient's awareness of stimuli on both sides of the body. The scoring is as follows:

• 0 = No neglect: The patient is aware of stimuli on both sides of the body.
• 1 = Neglect to one modality: The patient neglects stimuli in one modality (visual, tactile, auditory, spatial, or personal) when presented simultaneously on both sides of the body.
• 2 = Profound neglect: The patient neglects stimuli in multiple modalities or has profound neglect of one side of the body.

Key Considerations:

• Assess extinction and inattention by simultaneously presenting stimuli to both sides of the body.
• Observe the patient's response to visual, tactile, and auditory stimuli.
• Assess spatial neglect by asking the patient to draw a clock or copy a simple figure.
• Assess personal neglect by observing the patient's grooming and hygiene habits.

Interpreting the NIHSS Score

The total NIHSS score provides an overall assessment of stroke severity. The following categories are commonly used to interpret the NIHSS score:

• 0: No stroke symptoms
• 1-4: Minor stroke
• 5-15: Moderate stroke
• 16-20: Moderate to severe stroke
• 21-42: Severe stroke

It is important to note that the NIHSS score is just one factor to consider when evaluating a stroke patient. Other factors, such as the patient's age, medical history, and imaging results, should also be taken into account.

Factors Affecting NIHSS Accuracy

Several factors can affect the accuracy and reliability of the NIHSS, including:

• Inter-rater reliability: Differences in scoring between different examiners.
• Patient cooperation: The patient's ability to cooperate with the examination.
• Pre-existing conditions: Pre-existing neurological or medical conditions that can affect the assessment.
• Language barriers: Difficulty communicating with the patient due to language differences.
• Training and experience: The examiner's training and experience in administering the NIHSS.

To minimize these factors, it is important to:

• Use standardized training and certification for NIHSS administration.
• Ensure that examiners are experienced and proficient in administering the scale.
• Document any factors that may affect the accuracy of the score.

Conclusion

The NIHSS is a valuable tool for assessing stroke severity, monitoring changes in neurological status, and predicting patient outcomes. Accurate administration and scoring of the NIHSS are essential for reliable and valid results. By understanding the intricacies of the NIHSS and addressing the factors that can affect its accuracy, healthcare professionals can use this tool to improve the care and outcomes of stroke patients. The NIHSS provides a common language for clinicians, facilitating communication and collaboration in the management of this devastating condition. Continuous education and training are crucial to maintain proficiency in NIHSS administration and ensure its effective utilization in clinical practice and research.