National Institutes of Health Stroke Scale Workshop
Evaluation Options
There are many evaluation options included in the introduction of the NIHSS into practice. The first two relate to clinical
competency in performing and scoring the NIHSS. The last three refer to system and program evaluation. Evaluation tools
are provided for Options 1 & 2. Evaluation Tools for Options 3, 4,& 5 should be developed to meet the organization’s
needs and goals.
Option 1: Self-Assessment (Knowledge and Skills)
 Using Self-Assessed Competency of Neurological Assessment Techniques particular to the NIHSS form (see page 3).
 This self assessment is designed to be completed at the following points:


Pre-NIHSS education session
6 months post-NIHSS education to identify learning needs
Option 2: Clinical Performance Competency
 The workshop is designed to provide the participant with knowledge and skills required to confidently use the NIHSS in
the clinical setting.
 Competency is obtained through practice and interaction with the trainers/resource people in the clinical setting.
 Evaluation of competency in performing and scoring the NIHSS is done at the bedside using the Bedside Evaluation for
Clinical Competency form (see page 9).
Option 3: Evaluation of the Implementation Process
 Designated focus group sessions or one on one discussion with manager and/or educator can be used for this
evaluation component. Some topics to cover at this time can include:

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
Satisfaction, practice issues, and challenges.
Perceived impact of the NIHSS on communication between nursing colleagues, physicians and patients/families.
Perception of consistency, reliability and validity in the use of the NIHSS.
Perception on the effect of the NIHSS on quality of care for patients.
Option 4: Evaluation of Compliance
 Chart audits assessing compliance, documented communication of neurological decline, documentation of associated
interventions and follow-up can be completed at 6-9 months after implementing the NIHSS in practice.
Option 5: Evaluation of Sustainability
 Based on the evaluation components chosen, a formal review by team members of all information gathered is important
to identify issues for ensuring a sustainability plan.
NIHSS Evaluation Options, 2008
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Option 1: Self-Assessed Competency of Neurological Assessment Techniques
It is recognized that each person engaging in these education sessions comes with a foundation of knowledge and skills
acquired from experience. The purpose of these education sessions is to build on current abilities, facilitate professional
development and performance enhancement, and provide updated information regarding current best practices.
To facilitate an understanding of your strengths and areas for skill development, we ask you to complete the Self
Assessed Competency of Neurological Assessment Techniques. It is advisable to repeat this assessment in 6 months to
identify ongoing learning needs and the impact of the education that was received earlier.
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Self-Assessed Competency of Neurological Assessment Techniques
Circle one of the following:
Pre-NIHSS Education Questionnaire
OR
6 months Post-NIHSS Education Questionnaire
Name:
Years working:
Categories Used in This Self-Assessment
Use the following levels to determine your level of skill and knowledge in performing the competencies identified.
LEVEL
EXPERT
SKILL & KNOWLEDGE
Analysis, synthesis, application, *highly skilled performance

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
PROFICIENT
Extensive exposure, with deep understanding of situation
Able to rapidly and consistently identify actual and potential assessment changes
Able to rapidly change priorities under all conditions
Able to keep personal values in perspective and therefore able to encourage and support patient and family
choices
Conceptual understanding, *proficient performance




Extensive exposure in most situations
Able to anticipate potential assessment changes
Able to prioritize in response to changing situations
Able to interpret the patient and family experience from a wider perspective and can envision possibilities
NIHSS Evaluation Options, 2008
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LEVEL
COMPETENT
SKILL & KNOWLEDGE
Conceptual understanding and skill performance *competent




ADVANCED
BEGINNER
Varied exposure to many situations
Able to identify normal and abnormal findings
Able to prioritize under stable conditions
Increased awareness of patient and family viewpoints
Conceptual understanding, minimal clinical experience
 Limited exposure to clinical situations
 Able to identify normal findings
 Guided by what they need to do, rather than patient responses
NOVICE
 Marginal conceptual understanding, minimal clinical experience
 Seeks assistance in making clinical decisions
Benner, P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Menlo Park: Addison-Wesley
NIHSS Evaluation Options, 2008
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Stages of Competency
N
C
P
E
P= Proficient
AB
E= Expert
C= Competent
AB= Advanced Beginner
N=Novice
CLINICAL SKILLS, CRITICAL THINKING AND PROFESSIONAL BEHAVIOUR
1. I use a variety of neurological assessment techniques to collect data pertinent to my patients.
(a)
I am able to accurately determine the patients’ level of consciousness.
(b)
I incorporate neurological examination techniques to complete a
comprehensive assessment when assessing stuporous or comatose patients.
(c)
I am able to accurately assess the mental status of my patients including the
patient’s orientation, awareness, attention and concentration level,
comprehension, memory, reasoning and judgment.
(d)
I have the skills and knowledge to assess the patients’ gaze and extraocular
movements. I can determine a normal and abnormal response.
(e)
I am competent in the assessment of gross visual fields. I have the skills and
knowledge to determine a normal and abnormal response and identify
hemianopias.
(f)
I am able to accurately assess facial palsy. I incorporate testing into my
assessment to determine if the patient has motor weakness of the lower face
only or both the upper and lower face.
(g)
I am competent in the assessment of motor strength and drift. I utilize various
NIHSS Evaluation Options, 2008
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LEVEL
SKILL & KNOWLEDGE
assessment techniques to determine subtle weakness and changes in the
patients’ motor strength.
(h)
I am able to accurately assess limb ataxia. I use assessment strategies to
determine cerebellar impairment. I assess limb movement abnormalities in
relation to sensory or motor dysfunction.
(i)
I am competent in the assessment of sensation. I utilize light touch as well as
sharp/dull testing assessment techniques when appropriate based on the
patients diagnosis and situation.
(j)
I am competent in the assessment of expressive and receptive
communication deficits. I am able to perform a general assessment to
determine the patients’ ability to understand the spoken and written word and
to express thoughts orally and in writing.
(k)
I am competent in the assessment of dysarthria. I evaluate the patients’
clarity of speech.
(l)
I have the skills and knowledge to assess the presence or absence of
“neglect”. I assess inattention to aspects of the patients’ senses including
visual and tactile stimuli. I use assessment techniques to determine if a
patient is not aware of (or is unable to identify) physical deficits.
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LEVEL
SKILL & KNOWLEDGE
Stages of Competency
N
AB
C
P
P= Proficient
E
E= Expert
C= Competent
AB= Advanced Beginner
N=Novice
CLINICAL SKILLS, CRITICAL THINKING AND PROFESSIONAL BEHAVIOUR
2. I use a variety of assessment techniques and information sources to collect data pertinent to my neuroscience patients.
(a)
I determine the right data collection method based on my patient’s condition
(e.g. interviewing, listening, consulting, auscultating, percussing, observing,
palpating, inspecting, monitoring, measuring)
(b)
I use identified patterns/trends to direct further assessment needs and
synthesize all data to make care decisions
(c)
I identify potential and actual situations of patient risk based on assessment
results and take action to ensure patient safety
(d)
I communicate changes in patient condition and document situations and
outcomes to the appropriate authority in an objective and timely manner
3. I identify and prioritize nursing interventions.
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LEVEL
(a)
SKILL & KNOWLEDGE
I create a plan of care in collaboration with the patient and other team
members that is based on patient priorities
(b)
I develop a written plan of care
(c)
I identify interventions and modify the plan of care based on actual or
potential problems
4. I exercise professional judgment in decision-making.
(a)
I assess the risks and benefits of the required actions based on my patient’s
condition, determine the actions to be performed and can provide a rationale
for my decisions
(b)
I consult with others when I reach the limits of my knowledge and skill
5. I use problem-solving skills when responding to critical and ongoing situations.
(a)
I identify problems based on my patient’s condition and determine if the
problem is within my scope of practice
(b)
I decide appropriate actions considering possible risks and benefits and
collaborate with appropriate health care providers as necessary
NIHSS Evaluation Options, 2008
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Option 2: NIHSS Bedside Evaluation for Clinical Competency
Circle yes/no as appropriate. Shaded areas to aid evaluator
Identifies frequency of full assessment: YES
NO
1) TID during the first 72 hours after admission for stroke (or as per institutions guidelines)
2) With any decline in neurological status
3) When the patient is received from ER, ICU, or PACU onto unit
Name: _____________________
4) After the 72 hour period - with any changes in neurological status
Date: ______________________
S
CATEGORY
Description
Correctly identifies the following:
c
o
r
1a. Level of
consciousness
***(Patients who score
2 or 3 on this item,
should be assessed
using the Glasgow
Coma Scale)
Alert
e
0
Not alert
1
Not alert
2
Totally unresponsive
3
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Pt keenly responsive
Pt requires minor stimulation to obey, answer, or respond
Pt requires repeated or painful stimulation
Pt totally unresponsive (except reflexive effects)
Identifies correct score: YES NO
If pt scores 2 or 3, “Do you continue with this examination or refer to the GCS instead?”
Participant identifies the GCS is used INSTEAD of the NIHSS: YES NO
**Bedside NIHSS evaluation deferred for another pt.

NIHSS Evaluation Options, 2008
If pt scores 0 or 1, “Do you still complete the GCS as well as this document?” Participant
identifies the GCS is NOT completed YES NO
10
1b. LOC, questions
(month, age)
Answers both questions correctly
0


Answers one question correctly
1
Answers neither question correctly
2

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1c. LOC, commands
(Open/close eyes, make
fist,
release fist) Pantomime
may be used
2. Best gaze
(Patient follows
examiner’s finger or face
through full horizontal
field)




Performs both tasks correctly
0
Performs one task correctly
1
Performs neither task correctly
2

Normal
0
Partial gaze palsy
1



Forced deviation (not overcome by
oculocephalic maneuver)
2


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NIHSS Evaluation Options, 2008
Correct response ONLY includes correct Month, Age YES NO
“If the pt states their date of birth, corrects themselves, or comes close can you count this
as a correct response?”
The participant verbalizes such responses are incorrect: YES NO
“If pt correctly identifies the year, their date of birth, or the place, does this affect their score
on this item?”
Participant verbalizes the score for this item is based ONLY on month and age, not other
questions such as year, date or place: YES NO
Identifies correct score: YES NO
“Can you use pantomime in a pt that does not follow commands?”
Participant verbalizes pantomime can be used on this item: YES NO
“Can you substitute a different one-step command in a pt that is unable to use their hands?”
YES NO “Give an example of a one step command you could use.”
Participant verbalizes a one step command. YES NO
Assesses horizontal gaze (+/- other ocular movements): YES NO
Correct score identified (only scores pt as 1/2 if deficits are clearly present: YES NO
If unable to follow commands (confused, aphasic) uses tracking techniques to assess gaze:
YES NO
“Describe how you would assess a pt using “tracking”:
Participant able to identify technique for tracking (moving face in front of pt and/ or moving
about the room): YES NO
“Describe the oculocephalic technique. What would you see in a normal and abnormal
response? Able to identify technique for oculocephalic maneuver and is able to state the normal
response (eyes move opposite to direction head is turned) and abnormal response (eyes remain
fixed in one position when head is turned): YES NO
11
3. Visual
(Introduce visual
stimulus/threat to
patient’s field quadrants)
No visual loss
0


Partial hemianopia
1
Complete hemianopia
2


Bilateral hemianopia
3

Tests each eye independently and tests all 4 quadrants of each eye: YES NO
Correctly performs visual testing (asks pt to look directly into his/her eyes, asks pt to cover
one eye, introduces visual stimulus into each quadrant – visual threat used PRN): YES NO
“How do you assess an aphasic pt for visual loss?”
Participant identifies how to perform visual threat in a pt unable to follow usual visual
testing: YES NO
Please fill in the circles to demonstrate the following deficits:
Partial hemianopia
Complete hemianopia
correctly identifies these:
YES NO
Bilateral hemianopia
4. Facial palsy
(Show teeth, raise
eyebrows,
squeeze eyes shut)
Pantomime may be
used
Normal
0
Minor paralysis
1
Partial paralysis
2
NIHSS Evaluation Options, 2008
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Normal
Mild asymmetry on smiling (flattened nasolabial fold, fewer teeth on one side with smile)
Paralysis of lower face
Paralysis of upper and lower face (one or both sides)
identifies correct score: YES NO
“What is a flattened nasolabial fold?”
Participant identifies characteristics of a flattened nasolabial fold: YES NO

“Would you use pantomime in an aphasic patient who does not follow commands?”
12
Complete
3


5a. Motor arm - Left
No drift
0
(Test each limb
independently: Palm
Down: Elevate arm to
90 if pt sitting, 45 if pt
supine and score
drift/movement over 10
seconds)
5b. Motor arm – Right
Drift (drifts but does not fall to rest on a
support)
1
Some effort against gravity (drifts to
fall on support)
2
verbalizes he/she would use pantomime with such a pt: YES NO
“Could you use a cotton applicator tip to tickle each nasal passage of an aphasic or
lethargic pt to compliment your assessment of facial palsy?”
Participant verbalizes he/she can tickle each nasal passage to determining a valid
response: YES NO


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
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Correctly scores R arm: YES NO
Correctly scores L arm: YES NO
Asks patient to hold their hands in a “Palm Down” position: YES NO
Counts out loud for a full 10 seconds (or until arm hits support): YES NO
Tests each arm independently: YES NO
Places pt’s arms at 90 if pt sitting, 45 if pt supine: YES NO
“If the pt does not follow commands, what could you do to encourage them?”
Participant verbalizes he/she can position the pt’s arms at 90, use pantomime and use
urgency in his/her voice.: YES NO



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Correctly scores R leg: YES NO
Correctly scores L leg: YES NO
Tests each leg independently: YES NO
Counts out loud for a full 5 seconds (or until leg hits support): YES NO
Places pt’s in supine position and elevates leg to 30: YES NO
“If the pt does not follow commands, what could you do to encourage them?”
Participant verbalizes he/she can position the pt’s leg at 30, use pantomime and use
urgency in his/her voice: YES NO
No effort against gravity (trace
movement, limb falls immediately)
No voluntary movement
3
Amputation, joint fusion etc
4
6a. Motor leg – Left
No drift
(Test each limb
independently: With
pt supine, elevate
extremity to 30 and
score drift/movement
over 5 seconds)
6b. Motor leg - Right
Drift (drifts but does not fall to rest on a
support)
Some effort against gravity (drifts to
fall on support)
X
0
1
2
No effort against gravity (trace
movement, limb falls immediately)
No voluntary movement
3
Amputation, joint fusion etc
4
X
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7. Limb ataxia
(Finger-nose, heel down
shin)
8. Sensory
(Pin prick to face, arm,
trunk, and leg –
compare side to side)
Look at grimace in
aphasic patient
9. Best language
(Name item, describe a
picture and read
sentences)
Absent
0
Present in one limb
1
Present in two limbs
2
Normal
0
Mild to moderate sensory loss (less
sharp/dullness)
1
Severe or total sensory loss (not
aware of touch)




Correctly performs “finger-nose” testing: YES NO
Correctly performs “heel down shin” testing: YES NO
Only scores ataxia as being present if it is clearly demonstrated: YES NO
“In a patient with severe weakness or aphasia who is unable to follow directions, what score
would you give them on this item?” Ataxia is scored as 0 (absent) by the (because it can not be
clearly demonstrated that it is present): YES NO



Correctly scores sensory exam: YES NO
Uses a safety pin to test sensation: YES NO
Does not test sensation on hands or feet (rather uses arms and legs related to the
incidence of neuropathies in hands/feet): YES NO
Only scores the sensation as a 1 or 2 when it can be clearly demonstrated: YES NO
“If the patient had sensory deficits not related to the current stroke such as diabetic
neuropathy or other pre-existing conditions would you score only their stroke related sensory
loss, or also their sensory loss related to these conditions?”
Participant verbalizes that ONLY sensory deficits related to stroke are scored: YES NO


2
No aphasia
0
Mild to moderate aphasia (reduced
fluency or comprehension)
1
Severe aphasia (communication
exchange very limited)

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
Mute, global aphasia
10. Dysarthria
(Evaluate speech clarity
by having patient read
or repeat listed words)
Normal articulation
Mild to moderate dysarthria (can be
understood)
Severe dysarthria (unintelligible or
worse)
2
3
0
1





Correctly scores best language: YES NO
Asks pt to read all sentences and name all items: YES NO
“Would you encourage a non-verbal pt to write their responses?”
Participant verbalizes patients who cannot verbalize may write their responses: YES NO
“If a patient follows simple one-step commands, but does not express themselves using
speech, would you score them as a 2 or a 3?”
Participant verbalizes the patient would receive a score of 2, because they exhibit some
auditory comprehension: YES NO
“If the pt does not describe a portion of the picture, how would this affect your assessment
of extinction/inattention?”
Participant identifies double visual stimulation should be tested: YES NO
Correctly scores dysarthria: YES NO
Asks pt to read word list: YES NO
“If the pt were unable to read from the listed words, would you ask them to repeat after
you?”
Participant verbalizes they would ask the pt to repeat after him/her: YES NO
2
Intubated or other physical barrier
X
NIHSS Evaluation Options, 2008
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11. Extinction and
Inattention
(Use information from
prior testing to identify
neglect or double
simultaneous stimuli
testing)
No abnormality (no neglect)
0
Visual, tactile, auditory, spatial, or
personal inattention, or extinction to
bilateral stimulation in one of the
sensory modalities)
1




Profound: more than one modality
affected

2
TOTAL SCORE


Correctly scores extinction and inattention: YES NO
Performs double simultaneous testing of vision (L, R, both – tests upper and lower visual
fields) and tactile senses (with pts eyes closed asks “Which side am I touching? L, R, or both?”
– tests face, arms, legs): YES NO
“What is the difference between a score of 1 and 2?”
Participant verbalizes an understanding of the difference between a score of 1 (inattention
to one sensory modality) and a score of 2 (inattention to more than one sensory modality): YES
NO
“What score would you give to a patient who does not recognize their own hand as part of
their body?”
Participant verbalizes a score of 2 because the pt shows both tactile and personal
inattention. YES NO
Calculates a total score: YES
NO
 Records only actual patient response (not what he/she thinks the pt can do): YES NO
 Only uses coaching/pantomime for 1b LOC commands, 4. Facial or 5. & 6. Motor Arm/Leg: YES NO
NIHSS Evaluation Options, 2008
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