Using NIH Stroke Scale and

Accurate Documentation for Better

Patient Outcomes

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 It is important to perform a thorough neurological assessment of patients who
experience acute stroke for accurate diagnosis, treatment and care throughout

hospitalization. Proper observation of the changes in the patients’ condition will trigger

prompt initiation of medical or surgical interventions as well as facilitate measures that

aim at enhancing the outcome after stroke. The National Institutes of Health Stroke Scale

(NIHSS) is a well-validated and reliable scoring system that helps neurologists to

document the severity of neurologic deficits in acute stroke patients. Using NIH Stroke

Scale and proper documentation via accurate neurology transcription will ensure

effective patient care.

The Stroke Scale consists of 11 elements that reveal the wakefulness, vision and motor,

sensory and language function of stroke patients. You should record the results of each

examination step after performing each subscale examination. The answers to the

questions asked should be recorded while administering the examination. The scores

should signify what the patient does, not what you think the patient can do. The total

score obtained after performing all examinations should be recorded as well, which will

indicate the severity of stroke.

1a. Level of consciousness

The investigator is required to select a response even when full evaluation is prevented

by obstacles such as an endotracheal tube, language barrier, or orotracheal

trauma/bandages. A 3 score will be given only if the patient makes no movement over

noxious stimulation other than reflexive posturing.

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 0 = Alert; keenly responsive

1 = Not alert, but aroused by minor stimulation to obey, answer, or respond (drowsy)

2 = Not alert, needs repeated stimulation to attend, or is obtunded and requires

strong or painful stimulation to make any movement (stuporous)

3 = Responds only with reflex motor or autonomic effects or is totally unresponsive,

flaccid, or areflexic (coma)

1b. Level of consciousness questions

During this examination, the physician will ask the patient the name of the month and

his/her age. Here are the scores that can be given.

0 = Answers both questions correctly

1 = Answers one question correctly

2 = Answers neither question correctly

A score of 2 is given normally for aphasic and stuporous patients who do not

comprehend the questions while a score of 1 is given for patients who are not able to

speak as a result of endotracheal intubation, orotracheal trauma, severe dysarthria (from

any cause), language barrier, or any other problem not due to aphasia.

1c. Level of consciousness commands

The physician asks the patient to open and close the eyes and grip and release the

nonparetic hand after that. If it is not possible to use the hands, another one-step

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command is substituted. The results of this examination are scored. Only the first

attempt is considered for scoring. The scores are:

0 = Obeys both commands correctly

1 = Obeys one command correctly

2 = Obeys neither command correctly

2. Best gaze

The eye movements are tested during this examination. With the eyes open, patients are

asked to follow either the investigator’s finger or face. Only horizontal movements are

tested. The scores are as follows:

0 = Normal

1 = Partial gaze palsy; gaze abnormal in one or both the eyes, forced deviation or

total gaze paresis is not present.

2 = Forced deviation, or total gaze paresis is not overcome by the oculocephalic

(voluntary or reflexive) maneuver

3. Visual

Both the upper and lower quadrants of the visual fields are tested by confrontation

during this examination through finger counting or visual threat as appropriate. The

patient must be encouraged in this case. You should give the score 1 only if you find a

clear-cut asymmetry including quadrantanopia. The scores are given as follows:

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 0 = No visual loss

1 = Partial hemianopia

2 = Complete hemianopia

3 = Bilateral hemianopia (blind including cortical blindness)

4. Facial palsy

Encourage your patient to show the teeth, raise the eyebrows and close the eyes by

asking him/her or using pantomime. In a poorly responsive or non-comprehending

patient, score the symmetry of grimace in response to noxious stimuli. Make sure that

any physical barrier including facial trauma/bandages, orotracheal tube and tape that

obscures the face is removed to the extent possible.

0 = Normal symmetrical movements

1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling)

2 = Partial paralysis (total or near-total paralysis of lower face)

3 = Complete paralysis of one or both sides (absence of facial movement in the upper

and lower face)

5. Motor arm

This includes 5a Left arm and 5b Right arm. In this examination, the arms are extended

(palms down) to 90° (if sitting) or 45° (if supine). You should score the drift if the arm

falls before 10 seconds. Encourage an aphasic patient to use urgency in the voice and

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pantomime. But, it should not be noxious stimulation. Each limb needs to be tested in

turn, starting from the nonparetic arm. The scores are as follows:

0 = No drift; limb holds 90° (or 45°) for full 10 seconds

1 = Drift

2 = Can’t resist gravity

3 = No effort against gravity

4 = No movement

UN = Amputation or joint fusion

Give the score as untestable (UN) only in the case of amputation or joint fusion at the

shoulder. You should give the explanation for this choice as well.

6. Motor leg

This also includes 6a Left leg and 6b Right leg. You should hold the leg at 30° (always

tested supine) and drift should be scored when it falls before 5 seconds. The scores are:

0 = No drift; limb holds 30° for full 5 seconds

1 = Drift

2 = Can’t resist gravity

3 = No effort against gravity

4 = No movement

UN = Amputation or joint fusion

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7. Limb ataxia

The objective of this examination is to find evidence of a unilateral cerebellar lesion.

Testing is performed with the patient’s eyes open. The testing should be done in intact

visual field in case of visual defect. The finger-nose-finger and heel-shin tests need to be

performed on both sides. Score ataxia only if present out of proportion to weakness.

Ataxia is absent in the case of patient who cannot understand or is paralyzed. The scores

are:

0 = Absent

1 = Present in one limb

2 = Present in two limbs

UN = Amputation or joint fusion

8. Sensory

This involves testing the obtunded or aphasic patient’s sensation towards a painful

stimulus such as a pin prick. Only sensory loss attributed to stroke is scored as abnormal.

The examiner must test as many body areas as needed to accurately check for

hemisensory loss.

0 = Normal; no sensory loss

1 = Mild to moderate sensory loss

2 = Severe to total sensory loss

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9. Best language

Patients are asked to describe what is happening in a given picture, name items on the

given naming sheet, and read from a given list of sentences. The examiner should select

a score in the patient with stupor and non-co-operation. However, give the score of 3

only if the patient is mute and doesn’t follow any one step commands. If the patient is

suffering from visual loss, ask him/her to identify objects placed in the hand, repeat, and

produce speech. An intubated patient can be asked to write. The patient in coma will

score 3 on this item automatically.

0 = No aphasia

1 = Mild to moderate aphasia

2 = Severe aphasia

3 = Mute; global aphasia

10. Dysarthria

This examination technique deals with asking the patient to repeat the listed words to

evaluate the clarity of the speech. The score should be given as follows.

0 = Normal articulation

1 = Mild to moderate slurring of words

2 = Near to unintelligible or worse

UN = Intubated or other physical barrier

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11. Extinction and inattention (formerly neglect)

Use information obtained during prior testing to identify neglect or double simultaneous

stimuli testing in this case. The scores are:

0 = No neglect

1 = Partial neglect

2 = Complete neglect

Based on the total score, you can identify and record the severity of stroke in the

following way.

 0 - No stroke

 1-4 - Minor stroke

 5-15 - Moderate stroke

 15-20 - Moderate/severe stroke

 21-42 - Severe stroke

Since the NIHSS scores strongly predict outcome after stroke in this manner, the scores

can be used to help guide decision related to aggressiveness of care and dispositions.

The score provides a numerical value for comparison from time to time to objectively

track the neurological changes that occur rapidly. This provides a standardized means of

communication between care providers. NIHSS is also very helpful in identifying the

clinical findings that cause risk for complications in patients.

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