NIHSS Study Guide With Exam Questions And Answers.

NIHSSI - correct answer The National Institutes of Health Stroke Scale International Important Conventions - correct answer Administer scale items in their exact order Avoid coaching patient Accept patients first attempt Score only what patient does Be consistent Include all deficits in scoring 1A. Level of Consciousness (LOC) - correct answer Overall impression of alertness. 1A. Level of Consciousness (LOC) Scoring - correct answer 0 = Alert. 1 = Not alert; aroused with minor verbal stimulation. 2 = Not alert; requires strong or painful stimulation. 3 = Reflex movements only or totally unresponsive. 1A. Level of Consciousness (LOC) Exam - correct answer Ask patient questions about circumstances of admission. Stimulate patient by patting or tapping patient. Or noxious stimulation such as pinching or stern rub to check level of consciousness. 1A. Level of Consciousness (LOC) Assessment - correct answer LOC is the only item allowed to go back and change a score. If it is difficult to score between 1 or 2, continue with medical history questions until confident in assigning a score. Score must be chosen even if confronted with obstacles such as ET tube, language barrier, or oral tracheae trauma or bandages. Score 0, keenly responsive. Score 2, repeated verbal stimulation to attend, strong painful noxious stimulation to make movements. Score of 3 is generally considered to be in a coma. Score of 3 requires noxious painful stimuli by sternal rub. Only reflexive posturing movements in response to painful noxious stimuli. Requires particular attention as it impacts rest of exam. Continue with exam and attempt all following items. 1B. Level of Consciousness Questions - correct answer Question 1. Month of year Question 2. Patients age 1B. Level of Consciousness Questions Scoring - correct answer 0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly 1B. Level of Consciousness Questions Assessment - correct answer Only score initial answer. If patient gives an answer and then corrects himself, it is never the less scored as an incorrect answer. Many patients will give you their date of birth when you ask their age, this is scored as a wrong answer. No partial credit for being off by a month. Patients unable to communicate by ET tube, oral tracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are scored a 1. A patient who scores a 3 on LOC 1A must be scored a 2 on LOC 1B. If the patient is in a coma, a score of 2 would be assigned. Aphasiac and stuporous patients who do not comprehend the questions must be scored a 2. 1B. Level of Consciousness Questions Exam - correct answer Other measures of orientation such as time of day, location, ext. are not asked for this exam to ensure standardization and reproducibility of scoring. A patient who can not speak may be allowed to write the answer. 1C. Level of Consciousness Commands - correct answer Close your eyes for me, now open. Make a fist with your hand, and now open it up. 1C. Level of Consciousness Commands Exam - correct answer Ask patient perform two tasks. Before beginning this assessment, position the eyes and hands in a testable position. You may repeat the command once, but do not coach or encourage. In general, you should try to pantomime the command so the patient receives your verbal as well as visual input. If a patient does not speak english, a friend or family member can be asked to translate. 1C. Level of Consciousness Commands Scoring - correct answer 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly 1C. Level of Consciousness Commands Assessment - correct answer To improve reproducibility record what the patient does not what you think they are capable of doing. A 2 is scored for patients with a comprehension deficit and who perform incorrectly. Give credit if a real attempt is made but not completed due to weakness. Only score the first attempt. Do not coach or encourage. If you are dealing with patients with trauma, amputation, or other physical impediments, then substitute with other one step commands. 2. Best Gaze - correct answer Move your finger asking the patient to track your finger from side to side by moving the eyes only. 2. Best Gaze Scoring - correct answer 0 = normal gaze 1 = Partial gaze palsy 2 = Forced deviation 2. Best Gaze Exam - correct answer Tests voluntary horizontal eye movement. Disorders of vertical gaze, nystagmius, and skew deviation are not measured. First look at the position of the eyes at rest. Make sure to note any spontaneous eye movements to the left or right. The next test is to move your finger or other target horizontally asking the patient to track your finger from side to side by moving the eyes only. Make sure to keep asking the patient to follow the target. If the patient does not accurately follow your finger, a stronger test is needed. Use the ocular cephalic maneuver eye fixation or tracking of the examiners face. This is an exception to the rule of using the first observable response for scoring and not coaching the patient. In patients withs with poor attention spans establish eye contact and move your face around the patient from side to side, this may clarify the presence of a partial gaze palsy. Patients who scored a 3 on 1A level of consciousness are in a coma and may have gaze palsy that can be overcome by moving the head. So, in these cases you should use the ocular cephalic maneuver and score the result. To keep the testing conditions standard, do not do caloric testing. With aphasic patients, gaze is testable. Just like confused patients, it helps to establish eye contact and move about the bed. Patients with ocular trauma, bandages, pre-existing blindness, or other disorders of visual acuity or fields should be tested with reflexive movements and scored, this may mean removing the bandages. 2. Best Gaze Assessment - correct answer The easiest way to score this sightedness is to consider whether the eye movements are normal, if so score a 0. If not, consider whether there is tonic deviation such that the eyes cannot be moved, if so score a 2. Everything else will score a 1. If the patient has ocular rotary problems, such as a strabismus, but leaves the mid-line and attempts to look both right and left the patient should be considered to have a normal response. If there is a conjugate deviation from the eyes that can be overcome by voluntary or reflexive activity, also score a 1. If the patient has an isolated cranial nerve paralysis, such as an ocular motor or abducens palsy, also score a 1. Score a 2 when there is forced deviation or total gaze paralysis not overcome by the ocular cephalic maneuver. If there is a conjugate lateral deviation that is not overcome with reflexive movements, this score should be a 2. 3. Visual - correct answer Test the visual fields of both eyes independently. 3. Visual Scoring - correct answer 0 = No visual loss 1 = Partial hemianopia 2 = Complete hemianopia 3 = Bilateral hemianopia (blind including cortical blindness) 3. Visual Exam - correct answer Tests the visual fields of both eyes. Each eye is tested independently. Upper and lower quadrants are tested by confrontation, this means using finger movement, finger counting, or visual threat as appropriate. If a patient is unable to respond verbally, the examiner should check attention to responses to visual stimuli in all quadrants or have the patient hold up the number of fingers seen. Make sure the patient is looking directly into your eyes during the testing. Tell the patient you will be testing peripheral vision, and that you may move a finger to the right or a finger to the left or both. Then you test by asking the patient to count fingers in all four quadrants. Patients who scored a 3 on 1A LOC are tested using bilateral threat. 3. Visual Assessment - correct answer If the confused of language impaired individual looks in the direction of the moving finger, this is scored as normal. If a patient has severe monocular visual loss due to intrinsic eye disease and the visual fields in the other eye are normal, the examiner should score the visual fields as normal. Score a 1 only if you find a clear cut asymmetry including quadrantanopia or partial hemianopia. If there is an extinction, score the patient a 1. Score a 2 for a complete hemianopia. Score a 3 for blindness of any cause including cortical blindness which requires a positive diagnosis and double simultaneous stimulation testing. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. The results of this item will have an impact on the last scaled item of extinction and inattention. Many of us check double simultaneous stimulation to visual input at this point. There is an arbitrary rule that if they extinguish, the visual field item is scored a 1 even if the fields are intact to confrontation. This rule helps even out the variations that occur when inexperienced encounter