NIHSS Training

11 - Extinction/Inattention: Neglect Examined by double simultaneous stimulation. Ask them to close their eyes alntervatly touch their L and R side ask them what side is being touched, then touch both sides at once. Pt without neglect will identify touch on both sides, with cortical neglect they will usually only identify touch on one side. Also wiggle fingers on the R side and the L side and ask pt to identify if they were present on R, L, and.or both sides.

0 - absence of neglect 1- inattention to one modality, visual, tactile, spatial, or personal inattention. 2 - PRofound hemi inattention or exinction to more than one modaility. if one side

10- Dysarthria articulation and clarity of speech. Askk pt to read or repeat words from card.

0 - noiermal no slurring; crystal clear speech 1 - Slurred speech, anything less than crystal clear speech but not as bad as unintelligble. mild to moderate speech defects but can be understood. 2 - Almost unintelligible speech. Severe slurring, pt cannot be understood in any meaningful way or is mute. Untestable only if intubated or other physical barriers to speech.

LOC - 1a LOC Questions: MONTH OF THE YEAR and PT's AGE 1b

0 = Alert 1 = Not alert; aroused with minor verbal stimulation 2 = Not alert; requires strong or painful stimulation 3 = reflexive movements only or totally unresponsive. 0 - Answers both questions correctly 1 = Answers one question correctly 2 - answers neither question correctly

8 - Sensory Test with a series of pins pricks. Withdrawal of noxious stimuli in aphasic or obtunded pt. Examine pt with a pin in the proximal portions of all 4 limbs. Ask if pt feels the stimulus. Pt's eyes do not need to be closed. Ask if any asymmetry between right and left sides. Test on right and left sides at a time and see if they notice a different. Test arms, head, legs

0 = no evidence of loss 1= mild or moderate loss 2 = Severe or total sensory loss.

7 - Limb Ataxia Assessment for evidence un ilateral cerebellar lesion. Helps decipher between a brain issue and weakness. Perform finger noes finger and heel shin heel test on both right and left sides. Ask pt to touch your finger with his index finger than backj to his nose then back to my finger then back to his nose. Repeat enough times to thoroughly test for ataxia. then perform test on the other side. Then test in the leg, instruct pt to move the heel down and up the shin of the opposite leg. Give the same test on both the right and left sides of the body. Test the normal side first. Make sure pt eyes are open. In event of visual field defect try to perform test in intact visual field.

0: Absent: Normal coordination, the movments are well performed, smooth, and accurate and not clumsy. IF their is sig weakness, assume ataxia is 0. Ataxia is scored a 0 for 1= Present in 1 limb. 2= present in 2 limbs.

4 Facial Palsy: Assessment of facial palsy. You ask or use pantamine to ask them to show you their teeth or gums. Open or close they eyes. Squeeze them as hard as you can, lift up your eyebrows as high as you can. For non-responding use noxious stimuli.

0: Can do everything. 1: Minor paralysis = minor asymmetrical smile, flattened nasal labia fold. 2: Paralysis of lower face. Clear cut line. 3: complete paralysis of upper and lower face. Obtunded or comatose patient. Remember to use noxious stimuli if needed.

9 - Best Language Have them read a series of sentences, or look at objects on a card and describe the meaning and action depicted on the cookie jar image, encourage but do not coach, ask them to read all the phrases as well.

0: No Aphasia 1: Mild to moderate aphasia evidence by some obvious loss of fluency or facility of comprehension but no sigf limitation in ideas expressed. 2 = Severe aphasia: when all the pts expressions are fragementory or you cannot identify card content from the patient's response. 3 = Mute, global aphasia

6 - Motor Leg Same as arm, only they only need to hold up for 5 seconds.

0: No drift and leg holds 30 degree for full 5 1: DRFITS: and leg falls before 5 seconds is up 2: Some effort against gravity but falls before 5 seconds is up 3: no effort, and leg falls immediately. But pt still has hip and leg abduction 4: unable to make any voluntary movements.

3 - Visual: Tests visual field of both eyes. Make sure they are looking directly into your eyes. Ask pt to count fingers in all quadrants. Cover their right eye and show in left quadrant number of fingers for them to count. When they are LOC score of 3, use bilateral threat (hands cut in quadrants)

Score 0 - No visual loss in upper or lower fields. Able to blink to threat in all visual quadrants. Score 1 - PArtial hemianopia; Clear cut aysmmetry is considered partial hemianopia. This is when they can't see 1 quadrant Score 2: Blindess over half the field of vision. Complete Hemianopia is when they can't see an upper and lower side. Score of 3: Bilateral hemianopia (blind including cortical blindness)

1 LOC Commands: Ask pt to perform 2 tasks. 1c Close your eyes'. Now give me your hand. Score what pt does not what you think your capable of doing. Give credit though if a real attempt was made and they can't do it due to weakness.

Score 0 : Performs both tasks correctly 1 - One task correctly 2 - Neither task performed correctly

5 - Motor Arm Arm and Leg motor movement. Appropriately pisition limbs, extend the arms 90 degrees if sitting or 45 degrees if lying down. Always test legs in supine position by extending the leg 30 degrees. You score a drift if the arm falls before 10 seconds as you count down out loud. Or if the leg falls before 5 seconds. Begin counting immediately as soon as you drop the limb. Place the limb in the desired start position, wathc for an inital dip of the limb, only score abnormal if there is a downward drift after the dip. Palms must be down. Do not test them simultaneously and do not coach the patient. Use non paretic limb first.

Score of 0: No drift and arm remains in position Score of 1: Drift, jerks and drifts downward Score of 2: Drifts, maintains some effort against gravity, but the arm falls before 10 seconds.Eventually hits the bed before 10 seconds is up. Score of 3: No effort against gravity, but can still make voluntary movements. Score of 4: unable to make voluntary movements. To differentiate 3 and 4 you need to encourage the pt, any kind of movement such as a shoulder shrug or leg movement can help lower from 4 to 3.

2 - Best Gaze: Tests voluntary horizontal eye movements. Look at position of eyes at rest and note any spontaenoues eye movements at rest. Then ask pt to track finger by moving eyes only. If pt doesn't accurately follow finger. Partial Gaze palsy:

Score: 0 - Normal: tasks performed correctly. If they have strabismus but attempt to look right or left then they are counted as a 0. 1 = Partial Gaze Palsy 2 - Forced deviation Consider whether there are tonic deviations that indicate the eye cannot move from that place. this would be a 2. Consider whether the eye movements are normal, if so score a 0. everything else would be scored a 1.