Estructura miocárdica en el corazón hipertrófico

There are several places throughout the NIH Stroke Scale booklet, where exceptions to the general rules or creative adaptations are made to the

assessment of patients with problems expressing or receiving information. This document was designed to place all this information on one page for ease of understanding when using the NIHSS with the stroke survivor with aphasia. The differences in the overall NIHSS are highlighted below:

Item 1a: Level of Consciousness

• No difference in the exam.

1b. LOC Questions

• Aphasic and stuporous patients who do not comprehend the questions will

score 2 (answers neither question correctly).

• Patients may write their response.

1c. LOC Commands

• If the patient does not respond to command, the task should be demonstrated

to them (pantomime). Item 2: Best Gaze

• Gaze is testable in all aphasic patients.

• Establish eye contact and move about the bed with patients who are aphasic

or confused.

• Can coach and use best response as score.

• In the patient who fails voluntary gaze, use oculocephalic maneuver and

tracking of examiner’s face to provide stronger testing stimuli. Item 3: Visual

• If introducing your finger into visual quadrants as usual, the aphasic patient

can be asked: “Point towards my hand when you see my fingers move”.

• If patient looks at the side of the moving fingers appropriately, this can be

NIHSS and Aphasia, 2008 2

• If using visual threat: Test each eye independently x 4 quadrants (Upper and

lower nasal side & temporal side). Use a single finger briskly introduced into the visual field to see if a blink response” is elicited (Using an entire hand may result in a breeze that may cause reflexive blinking).

Item 4: Facial Palsy

• Ask and use pantomime to encourage.

• "Show me your teeth ... now raise your eyebrows ... now close your eyes

tightly".

• Score symmetry of grimace to noxious stimulation (such as tickling each

nasal passage with a cotton applicator tip) in the aphasic or confused patient. Items 5 & 6: Motor Arm and Leg

• Place the patient’s arm or leg in the desired starting position.

• Encourage the patient using urgency in the voice and pantomime but not

noxious stimulation.

• Count OUT LOUD in a strong voice and indicate count using your fingers in

full view of the patient. Item 7: Limb Ataxia

• Non verbal cues are permitted.

• The patient will often perform the test normally if first the limb is passively

moved by the examiner.

• Ataxia is only scored if present. In a patient who cannot understand the exam

or who is paralyzed, a score of 0 (absent) is given.

• If the weak patient suffers mild ataxia and you cannot be certain that it is out

of proportion to the weakness, give a score of 0. Remember this is scored positive only when ataxia is present.

Item 8: Sensory

• If the patient has some ability to express themselves, for example, “Yes/No”,

shaking or nodding head, or pointing to the limb touched: Ask: “Can you feel the pin prick” “Is it the same or different?” “Which side is different?” etc.

• Record grimace or withdrawal from noxious stimulus in patients who are

obtunded or have aphasia (only if no response is demonstrated with the safety pin).

• Only record sensory loss if it is clearly demonstrated.

• Patients with aphasia often score 0 or 1 (since clearly demonstrating severe

NIHSS and Aphasia, 2008 3

Item 9: Best Language

• This portion of the exam is complimented by information collected in

preceding sections.

• Encourage patient to write their responses to the naming items or picture

description.

• Score “Tips”:

• 0 = No aphasia, normal fluency and comprehension

• 1 = Mild to moderate aphasia – some obvious loss of fluency or

comprehension, but the patient is able to “get their ideas across” in general

• 2 = Severe aphasia – all communication very limited, examiner must

guess what the patient is trying to communicate

• 3 = Mute, global aphasia – NO useable speech, NO auditory

comprehension. (Pt unable to follow any one step commands)

• To choose between a score of 1 or 2 use all the provided materials. It is

anticipated that a patient who missed more than two thirds of the naming objects and sentences or who followed only very few and simple one step commands would score a 2.

Item 10: Dysarthria

• Ask the patient to repeat the listed words after you read them out loud. • Score patients based on listening to the speech that they do produce. • Determine if any slurring of speech is present using the above information

and score the patient accordingly.

• If no intelligible speech is produced or the patient is mute: Score a 2 (severe

dysarthria).

Item 11: Extinction & Inattention (Neglect)

• Test bilateral simultaneous visual fields by asking patient to point to L, R, or

both of examiners fingers when doing visual exam.

• Test recognition of bilateral simultaneous touch to upper and lower limbs

(patient’s eyes closed) by asking patient to point to side(s) being touched (L, R, or both).

• If the patient has aphasia but does appear to attend to both sides, the score is

normal.