NIHSS

limb ataxia

- Have pt touch finger to their nose, then to your finger. Move yr finger. Watch how coordinated their movements are. - Have pt place heel on opposite shin, then slide it slowly up and down his shin. 0 - smooth and coordinated movements in all extremities 1 - uncoordinated movements in ONE limb, more than just weakness 2 - uncoordinated movements in TWO limbs Pts who are difficult to arouse / cannot follow movements receive a zero score.

Visual Fields Test

-Cover pt's eye 1 at a time, test each eye separately. -Have pt look at yr nose -Show 1-2 fingers in visual fields (up/down/left/right), ask how many fingers holding up -If pt cannot see, slowly move hand towards pt's nose, ask them to tell you when they can see your fingers 0 - no visual field loss 1 - partial hemianopia (pt can't see up or down fields, same loss in BOTH eyes) 2 - complete hemianopia (pt can't see full left or full right fields, same loss in BOTH eyes) 3 - bilateral hemianopia (pt is blind) -Unilateral blindness: score visual field in the eye that can see -Visual threat for pts that can't follow commands

For NIHSS, a higher score signifies...

more deficits (worse condition)

Level of Consciousness Commands

Ask pt to follow 2 simple commands (e.g. open and close eyes, grip hand) 0 - follows both commands 1 - follows 1 command 2 - follows no commands correctly

Best Gaze Score (horizontal eye movements)

Ask pt to follow finger from side to side, watch their eye movements 0 = Normal and smooth eye movements side to side 1 = Partial gaze, abnormal gaze in one or both eyes 2 = Forced eye deviation or total paresis, eyes stuck to one side or cannot pass midline If pt does not follow commands, make eye contact and move from one side of bed to the other, see if maintains eye contact

motor - arm

Ask pt to lift up arms w/ palm down, one arm at a time. Can help by lifting arm for pt. Count out loud to 10. 0 - no drift 1 - drift, but does not drop on bed by count of 10 2 - some resistance, but falls to bed before 10 3 - no effort against gravity, falls immediately to bed, can move shoulder though 4 - no movement (arm falls to bed immediately, no shoulder movement)|

motor - leg

Ask pt to lift up their leg, one leg at a time. Can help by lifting up their leg. Count out loud to 5. 0 - no drift 1 - drift, but does not touch bed by count of 5 2 - some effort against gravity / resistance, but falls before count of 5 3 - no effort against gravity, falls immediately to bed, but has some leg/hip movement 4 - no movement, falls immediately to bed

Dysarthria

Ask pt to read or repeat back words on sheet. Listen for slurring. 0 - normal articulation 1 - can understand words despite slurring, mild to moderate dysarthria 2 - severe dysarthria, difficult to understand words Coma pts - 2

facial palsy

Ask pt to smile, blow out cheeks, lift up eyebrows, observe facial movements 0 - normal symmetry 1 - minor paralysis: asymmetrical smile, flattened nasolabial fold 2 - partial paralysis, lower face only 3 - complete paralysis, both forehead and lower facial weakness Pt's facial droop is only noticeable when smiling? = Score of 1 Obvious lower facial droop = Score of 2

oculo-cephalic reflex

Does pt's eye stay fixed on same object even if their head is moved from side to side? No eye movement across midline = negative oculo-cephalic reflex = doll's eye = Best Gaze score of 2

Extinction / Inattention

Have pt look at yr nose, hold both hands up and wiggle one hand. Ask pt to point to hand that is moving. Wiggle both hands and ask pt to point or state which hands are moving. Have pt close eyes, ask them to tell you which side you are touching or tapping: R, L, or both. Check on pt's cheeks, arms, and legs. 0 - normal 1 - pt cannot see / feel both sides when hands are wiggling OR when pt is being touched both sides at same time 2 pt cannot see both sides AND pt cannot feel both sides at same time If pt has severe vision loss but no other issues w/ identifying stimulation - Score 0 Pt cannot follow commands - Score 0

Sensory

Have pt's eyes open. Use a SHARP point to touch pt on one side of face and then other, ask if pt can feel and if it feels the same or different. = face, arms, legs 0 - normal 1 - mild to moderate loss 2 - severe to total sensory loss -do not test hands/feet, pt may have peripheral neuropathy Pts who do not follow commands = score 0 Comatose pts = score 2

Level of Consciousness Test

Observe pt's alertness Call pt by name to awaken if asleep If no response, physical stimulation 0 - alert 1 - arouses to minor stimulation 2 - needs repeated stimulation to arouse 3 - only responds w/ reflex motor/autonomic effects

complete hemianopia

a defect of the ENTIRE right or left hemifield

partial hemianopia

can't see out of either the superior OR the inferior half of their visual field (left or right)

Language

Use language sheets w/ objects, scene w/ mom and children, ask pt to name items. 0 - no aphasia 1 - mild to moderate 2 - severe 3 - mute Comatose pts = score 3

If a patient is not following commands, how can you assess visual fields?

Visual Threat: 0 - pt blinking in both eyes to threat 2 - blinks in only one eye 3 - patient is blind

Level of Consciousness Questions

What month is it? How old are you? 0 - both answered correctly 1 - one answered correctly 2 - both answers wrong For aphasic pts: give options, ask pt to nod at correct option