 Neurological Exam

 Reliably predicts outcome

 Tool to track changes over time

 Standardized method of documentation

 NIHSS is a quantative tool used to ensure
reliability of scores between testers. It gives
other members of the healthcare team a
reliable indication of patients condition
 NIHSS is also a predictor of morbidity
and mortality
 The NIHSS measures 5 areas of
neurological function:

 Wakefulness-items 1.a,b,c
 Vision-items 2&3
 Motor –item 4,5,6&7
 Sensory-items 8&11
 Language& Speech-items 9&10
 Range from 0-42
 0= normal
 <4=mild
 5-10=mild to moderate
 10-20=moderate
 >20=severe
 Administer Stroke Scale Items in the order
listed

 Do not go back and change scores

 Follow directions for each exam technique

 Score what the patient does; not what you

think they can do
 Do not coach the patient

 All items must be scored

 Include all deficits in scoring , even those

from prior strokes
 ALERT(0)
 Keenly responsive
 Aware of self and environment

Not Alert(1)
 Arousable by minimal stimulation to
obey, answer, or respond
 Not Alert(2)
 Requires repeated stimulation
 May need strong stimuli to make
movements

Not Alert(3)
 Totally unresponsive, and flaccid
 No localization to noxious stimuli
 Ask patient the month and their
age

 0=answers both questions correctly

 1=answers one question correctly
 2=answers neither question correctly
  Score the First Answer
 No cues Allowed
 Other Orientation questions cannot
count
 Aphasic patients score 2
 Unable to speak bc of intubation or any
other problem not secondary to aphasia
give a 1
 Close your eyes and open them
Make a fist with your hand

0=performs task correctly

1=performs one task correctly
2=performs neither task correctly
 Mime with making a fist while asking
question

 May repeat command once but do not

coach or encourage patient

 If an effort is made but cannot perform

the task secondary to weakness-give
credit
 Only Horizontal Eye Movements are
tested

 0=Normal
 1=partial gaze palsy; gaze is abnormal in
one or both eyes, but forced deviation or
total gaze paresis is not present
 2=Forced deviation, or total gaze paresis
not overcome by the ocular cephalic
maneuver
 If pt has an isolated peripheral nerve
paresis (CN 111,1V,or VI),score 1

 Gaze is testable in all aphasic patients

 Preexisting blindness should be tested

with reflexive movements
 Tested by confrontation

One eye at a time

Using Finger counting or Visual threat

 0=no visual loss

 1=Partial hemianopia
 2=Complete hemianopia
 3=Bilateral hemianopia
 Blind in one eye-then score the other eye

 Blind in both eyes=3

 If Aphasic-test using threat

 Ask patient to show teeth/smile raise
eyebrows, squeeze eyes shut

 0=normal
 1=minor paralysis(asymmetry of smiling)
 2=partial paralysis
 3=complete paralysis (absence of facial
movement in the upper and lower face)
Test grimace for Aphasic patients
Extend the arms ,palms down to 90 degrees(if sitting)
and 45 degrees (if supine) for a full 10 seconds

 0=no drift
 1=drift-limb holds but drifts down before full 10
seconds .Does not hit bed
 2=some effort against gravity, but drifts down to
bed
 3=no effort against gravity, limb falls
 4=no movement
 Un=amputation or joint fusion
 Initial dip of the limb is allowed, only
score if limb drifts after a dip

 Test one limb at a time

 Count down with your finger in full vies of

patient
 Elevate leg off bed for 5 seconds
 0=no drift
 1= drift leg falls by the end of the 5 second period
but does not hit bed
 2=some effort against gravity; leg falls to bed by 5
seconds, but has some effort against gravity
 3=No effort against gravity; leg falls to bed
immediately
 4=No movement
 UN=Amputation
 If coma : 5 & 6 are scored 4

 Always test leg while patient is supine

 You may help patient by placing leg at

desired postion
 Finger to nose and heel to shin on both
sides

 0=absent
 1=present in one limb
 2=present in two limbs
 Un=Amputatition
 Test arms before legs
 Make sure this done in the intact visual
field with patients eyes open
 Ataxia out of proportion to weakness is
scored
 If patient is aphasia or in a coma score 0
 If you cannot test you cannot score
 Test with a pin on the proximal extremity

 0= no sensory loss
 1=mild to moderate sensory loss(less
sharp or dull on affected side; aware of
being touched)
 2=Severe to total sensory loss(pt is not
aware of being touched)
 Score of 2 is very rare, must have complete sensory loss

Compare sides: do not ask sharp or dull

Score bare skin: not through clothing

Aphasic Patient-test withdrawal of limb from noxious

stimulus
Comatose=2

Brainstem stroke –bilat loss of sensation=2

 This assessment tests comprehension

Objective Test: Cookie Jar Picture

Read Sentences
Name objects

 0=no aphasia
 1=mild to mod aphasia
 2.Severe aphasia
 3. Mute or global aphasia(no usable speech)
 Coma or stupor-3
 If visual impaired can hold objects in the
hand
 If patient wears glasses the should use
them
 Intubated patients may write
 Cultural implications
 Evaluate Speech Clarity ask patient to
repeat listed words
 0=normal articulation

 1=mild to mod dysarthria-pt slurs at least some

words

 2=severe dysarthria ,pt speech is so slurred that it is

unintelligible or mute

 UN=intubated
 Unresponsive or comatose =2

 Mute Patient =2

 If difficulty understanding because of no

teeth =1
Hold your fingers in upper and lower quads
(R&L)of pts visual field , ask them which
fingers are wiggling R,L or both
Test for both last to ensure that patient can
distinguish
R from L
Pt should be looking straight ahead
•0=no abnormality

•1-Visual,tactile,auditor,spatial,or
personal inattention or extinction to
bilat simultaneous stimulation in one of
the senor modalities

•2=Profound -
Visual,tactile,auditor,spatial,or personal
inattention or extinction to bilat
simultaneous stimulation in both of the
sensor modalities
(does not recognize own hand or
orients to only one side of space)
 Have patient close his eyes and the
touch their face ,arms, and legs
alternating R/L/both.

 1 indicates a loss to either sensory or

vision testing
 2.indicates a loss of both sensory and
vision testing
 Blind person, intact sensory attention =0

 Aphasia ,use best judgment