Nihss Stroke Scale Answers And Interpretation Guide

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The National Institutes of Health Stroke Scale (NIHSS) is a widely used assessment tool for evaluating the severity of stroke and monitoring patients' progress over time. As a healthcare professional, understanding the NIHSS and its interpretation is crucial for providing effective care to stroke patients.

The NIHSS consists of 11 items that assess various aspects of a patient's neurological function, including level of consciousness, best gaze, visual fields, motor strength, ataxia, dysarthria, and language. In this article, we will provide an in-depth guide to the NIHSS, including answers and interpretation of each item.

Understanding the NIHSS Scoring System

Before diving into the individual items, it's essential to understand the NIHSS scoring system. Each item is scored on a scale of 0 to 4, with 0 indicating normal function and 4 indicating severe impairment. The total score ranges from 0 to 42, with higher scores indicating more severe stroke symptoms.

Item 1: Level of Consciousness (LOC)

The LOC item assesses the patient's level of awareness and responsiveness. A score of 0 indicates that the patient is alert and responsive, while a score of 3 indicates that the patient is comatose.

• 0: Alert and responsive
• 1: Not alert, but arousable to voice
• 2: Not alert, and not arousable to voice, but responsive to pain
• 3: Comatose, not responsive to voice, pain, or other stimuli

Item 2: Best Gaze

The best gaze item assesses the patient's ability to follow commands and move their eyes in response to visual stimuli. A score of 0 indicates that the patient can follow commands and move their eyes normally, while a score of 2 indicates that the patient has a conjugate gaze deviation.

• 0: Normal gaze
• 1: Partial gaze palsy
• 2: Conjugate gaze deviation

Item 3: Visual Fields

The visual fields item assesses the patient's ability to perceive visual stimuli in their peripheral fields. A score of 0 indicates that the patient has normal visual fields, while a score of 3 indicates that the patient has a complete hemianopia.

• 0: Normal visual fields
• 1: Partial hemianopia
• 2: Complete hemianopia
• 3: Bilateral hemianopia

Item 4: Motor Strength (Face)

The motor strength (face) item assesses the patient's ability to move their facial muscles in response to commands. A score of 0 indicates that the patient has normal facial strength, while a score of 4 indicates that the patient has a complete facial paralysis.

• 0: Normal facial strength
• 1: Mild facial weakness
• 2: Moderate facial weakness
• 3: Severe facial weakness
• 4: Complete facial paralysis

Item 5: Motor Strength (Arm)

The motor strength (arm) item assesses the patient's ability to move their arm in response to commands. A score of 0 indicates that the patient has normal arm strength, while a score of 4 indicates that the patient has a complete arm paralysis.

• 0: Normal arm strength
• 1: Mild arm weakness
• 2: Moderate arm weakness
• 3: Severe arm weakness
• 4: Complete arm paralysis

Item 6: Motor Strength (Leg)

The motor strength (leg) item assesses the patient's ability to move their leg in response to commands. A score of 0 indicates that the patient has normal leg strength, while a score of 4 indicates that the patient has a complete leg paralysis.

• 0: Normal leg strength
• 1: Mild leg weakness
• 2: Moderate leg weakness
• 3: Severe leg weakness
• 4: Complete leg paralysis

Item 7: Ataxia

The ataxia item assesses the patient's coordination and balance. A score of 0 indicates that the patient has normal coordination and balance, while a score of 2 indicates that the patient has a severe ataxia.

• 0: Normal coordination and balance
• 1: Mild ataxia
• 2: Severe ataxia

Item 8: Dysarthria

The dysarthria item assesses the patient's ability to articulate words and speak clearly. A score of 0 indicates that the patient has normal speech, while a score of 2 indicates that the patient has a severe dysarthria.

• 0: Normal speech
• 1: Mild dysarthria
• 2: Severe dysarthria

Item 9: Language

The language item assesses the patient's ability to understand and express language. A score of 0 indicates that the patient has normal language function, while a score of 3 indicates that the patient has a severe aphasia.

• 0: Normal language function
• 1: Mild aphasia
• 2: Moderate aphasia
• 3: Severe aphasia

Item 10: Extinction and Inattention

The extinction and inattention item assesses the patient's ability to attend to and respond to visual and tactile stimuli. A score of 0 indicates that the patient has normal attention and extinction, while a score of 2 indicates that the patient has a severe extinction and inattention.

• 0: Normal attention and extinction
• 1: Mild extinction and inattention
• 2: Severe extinction and inattention

Item 11: Orientation

The orientation item assesses the patient's ability to orient themselves to time, place, and person. A score of 0 indicates that the patient is fully oriented, while a score of 2 indicates that the patient is disoriented to time, place, and person.

• 0: Fully oriented
• 1: Disoriented to one aspect (time, place, or person)
• 2: Disoriented to two or more aspects (time, place, and person)

Interpretation of NIHSS Scores

The NIHSS score can range from 0 to 42, with higher scores indicating more severe stroke symptoms. The following is a general interpretation of NIHSS scores:

• 0-5: Mild stroke symptoms
• 6-10: Moderate stroke symptoms
• 11-20: Severe stroke symptoms
• 21-42: Very severe stroke symptoms

Gallery of NIHSS Assessment Tools

Frequently Asked Questions