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NIH Stroke Scale (NIHSS) – Stroke Nursing Care in ER

by Rhonda Lawes

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    00:01 Okay. We've looked at a set of initial healthcare orders.

    00:04 Now I want to introduce you to the NIH Stroke Scale.

    00:08 That's the National Institutes of Health Stroke Scale, so you'll often heard it just called NIHSS.

    00:14 This is a standardized tool that's used across the United States to evaluate potential stroke patients.

    00:20 So, you'll receive special training once you're a practicing nurse, and usually, they're members on the stroke team that respond that have been trained in this scale.

    00:29 So the score for each ability is a number between 0 and 4.

    00:33 0 is normal functioning, and 4 is completely impaired.

    00:37 So 42 is the highest, and the higher the score, the more impairment the patient's experiencing.

    00:44 So it's not important that you look at the specifics of it. I just want you to be aware that this is a standardized tool. It's an efficient way to consistently assess patients and see where they stand, because most people are familiar with this in the healthcare world, that the higher the score, the more severe the possibility of impairment.

    01:03 Okay. So they've got multiple neurological items on each stroke scale.

    01:07 They look at level of consciousness, language, neglect -- remember we talked about right and left side neglect. They've got some problems with their visual field, some weird eye movements, extraocular movements, their motor strength, we'll look and see if it is equal on both sides.

    01:25 Ataxia, problems with movement, Dysarthria is a motor speech disorder caused by weakness in the muscles used to speak, often resulting in slowed or slured speech.

    01:35 Or they have some sensory loss. So, this is not a slide for you to memorize.

    01:41 This is just information for you to know. These are the categories that we would look at each one of these items, the one who is trained, will do the NIH stroke scale, score it, and come up with a total number.

    01:53 Takes less than 10 minutes to complete. It can be done by a certified nurse or a physician. So, remember, you need special training in this scale to evaluate the patient. Now, we do it in the patient that's admitted, so this would likely be done in the ER. It'll give us a baseline to know where the patient was.

    02:11 Now, neuro patients can change for lots of different reasons.

    02:15 So we're going to do it at the baseline, when they come in. We're going to it 2 hours after whatever treatment is decided upon, then likely at 24 hours, after symptoms, then 7-10 days, 3 months, etc. Now that timetable can be adjusted based on what each patient needs, but the important takeaway points are, it's quick. If you're trained, < 10 minutes to do a very thorough exam and we'll utilize it it to see how the patient is progressing, either getting better or losing some ground.


    About the Lecture

    The lecture NIH Stroke Scale (NIHSS) – Stroke Nursing Care in ER by Rhonda Lawes is from the course Neurology Case Study: Nursing Care of Stroke Patient.


    Included Quiz Questions

    1. Altered level of consciousness and potentially more impairment present
    2. No deficits
    3. Temporary limb weakness
    4. Permanently altered level of consciousness
    1. A certified nurse or a physician
    2. Anyone involved in the care of the client
    3. Only a trained physician on the stroke team
    4. Family of the client or any staff member in the hospital

    Author of lecture NIH Stroke Scale (NIHSS) – Stroke Nursing Care in ER

     Rhonda Lawes

    Rhonda Lawes


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