ARCHETYPE ID | openEHR-EHR-OBSERVATION.stroke_scale_neurological_assessment.v0 |
Concept | Stroke scale neurological assessment (NIHHS) |
Description | 15-item neurologic examination stroke scale used to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome. Also known as the National Institutes of Health Stroke Scale (NIHSS) |
Use | Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly. Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort) |
Purpose | To record a systematic quantitative measurement of stroke-related neurologic deficit. The NIHSS was originally designed as a research tool to measure baseline data on patients in acute stroke clinical trials. Now, the scale is also widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome. |
References | American Academy of Neurology. NIH Stroke Scale Neurological Assessment Flow Sheet. Available at: http://www.aan.com/globals/axon/assets/6285.pdf. Accessed May, 2012. National Institute of Neurological Disorders and Stroke. NIH Stroke Scale. Available at: http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale_Booklet.pdf. Accessed May, 2012. National Stroke Association. NIH Stroke Scale. Available at: http://www.stroke.org/site/PageServer?pagename=NIHSS. Accessed May, 2012. NIH Stroke Scale (NIHSS) International. Available at: http://www.nihstrokescale.org/. Accessed May, 2012. |
Copyright | © openEHR Foundation |
Authors | Author name: Gustavo M Bacelar-Silva Organisation: Healthcare Designs Email: mail@gustavobacelar.com Date originally authored: 11-05-2012 |
Other Details Language | Author name: Gustavo M Bacelar-Silva Organisation: Healthcare Designs Email: mail@gustavobacelar.com Date originally authored: 11-05-2012 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 3.0 License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/3.0/., custodian_organisation=openEHR Foundation, references=American Academy of Neurology. NIH Stroke Scale Neurological Assessment Flow Sheet. Available at: http://www.aan.com/globals/axon/assets/6285.pdf. Accessed May, 2012. National Institute of Neurological Disorders and Stroke. NIH Stroke Scale. Available at: http://www.ninds.nih.gov/doctors/NIH_Stroke_Scale_Booklet.pdf. Accessed May, 2012. National Stroke Association. NIH Stroke Scale. Available at: http://www.stroke.org/site/PageServer?pagename=NIHSS. Accessed May, 2012. NIH Stroke Scale (NIHSS) International. Available at: http://www.nihstrokescale.org/. Accessed May, 2012., original_namespace=org.openehr, original_publisher=openEHR Foundation, custodian_namespace=org.openehr, MD5-CAM-1.0.1=DBF0240F5AFF927A8E1B45323D9570ED, build_uid=65f94f39-3493-4abc-b696-a80bda87a6fe, revision=0.0.1-alpha} |
Keywords | scale, neurological, stroke, assessment, examination |
Lifecycle | in_development |
UID | 3f64e10e-e330-4a6a-8a54-68f4941c0b88 |
Language used | en |
Citeable Identifier | 1051.32.537 |
Revision Number | 0.0.1-alpha |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=null, archetypeConceptDescription=15-item neurologic examination stroke scale used to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome. Also known as the National Institutes of Health Stroke Scale (NIHSS), archetypeConceptComment=null, otherContributors=Silje Ljosland Bakke, Nasjonal IKT HF, Norway (openEHR Editor) Rong Chen, Cambio Healthcare Systems, Sweden Ricardo Cruz-Correia, Faculty of Medicine of Porto University, Portugal, originalLanguage=en, translators= , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={content=[], description=[], details=[], source=[], capabilities=[], other_participations=[], protocol=[ResourceSimplifiedHierarchyItem [path=/protocol[at0098]/items[at0108], code=at0108, itemType=ELEMENT, level=2, text=*Time(pt), description=*Moment when the test was performed(pt), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=Full Date and Time, extendedValues=null]], provider=[], activities=[], state=[], events=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002], code=at0002, itemType=POINT_EVENT, level=2, text=Baseline, description=Baseline assessment., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0158], code=at0158, itemType=POINT_EVENT, level=2, text=2 hours post treatment, description=Assessment 2 hours post treatment., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=Offset: 2 hours , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0159], code=at0159, itemType=POINT_EVENT, level=2, text=24 hours post onset of symptoms 6 minutes, description=Assessment 24 hours post onset of symptoms (with tolerance of +-20 minutes)., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=Offset: 24 hours , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0160], code=at0160, itemType=POINT_EVENT, level=2, text=7–10 days, description=Assessment made at point in time between 7-10 days., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=null, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0161], code=at0161, itemType=POINT_EVENT, level=2, text=3 months, description=Assessment after 3 months., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=POINT_EVENT, bindings=null, values=Offset: 3 months , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0162], code=at0162, itemType=EVENT, level=2, text=Other, description=*, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=EVENT, bindings=null, values=null, extendedValues=null]], ism_transition=[], data=[ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004], code=at0004, itemType=CLUSTER, level=4, text=Consciousness, description=Consciousness, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText= , subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004]/items[at0005], code=at0005, itemType=ELEMENT, level=5, text=Level of Consciousness, description=The investigator must choose a response if a full evaluation is prevented by such obstacles as an endotracheal tube, language barrier, orotracheal trauma/bandages. A 3 is scored only if the patient makes no movement (other than reflexive posturing) in response to noxious stimulation., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Alert [Keenly responsive.] 1: Drowsy [Not alert; but arousable by minor stimulation to obey, answer or respond.] 2: Stuporous [Not alert; requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped).] 3: Coma [Responds only with reflex motor or autonomic effects, or totally unresponsive, flaccid, and areflexic.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004]/items[at0010], code=at0010, itemType=ELEMENT, level=5, text=Level of Consciousness Questions, description=The patient is asked the month and his/her age. The answer must be correct — there is no partial credit for being close. Aphasic and stuporous patients who do not comprehend the questions will score 2. Patients unable to speak because of endotracheal intubation, orotracheal trauma, severe dysarthria from any cause, language barrier, or any other problem not secondary to aphasia are given a 1. It is important that only the initial answer be graded and that the examiner not “help” the patient with verbal or non-verbal cues., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Answers both correctly [*] 1: Answers one correctly [*] 2: Incorrect [*] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0004]/items[at0014], code=at0014, itemType=ELEMENT, level=5, text=Level of Consciousness Commands, description=The patient is asked to open and close the eyes and then to grip and release the non-paretic hand. Substitute another one-step command if the hands cannot be used. Credit is given if an unequivocal attempt is made but not completed due to weakness. If the patient does not respond to command, the task should be demonstrated to him or her (pantomime), and the result scored (i.e., follows none, one, or two commands). Patients with trauma, amputation, or other physical impediments should be given suitable one-step commands. Only the first attempt is scored., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Performs both tasks correctly [*] 1: Performs one task correctly [*] 2: Performs neither task correctly [*] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0018], code=at0018, itemType=ELEMENT, level=4, text=Best Gaze, description=Only horizontal eye movements will be tested. Voluntary or reflexive (oculocephalic) eye movements will be scored, but caloric testing is not done. If the patient has a conjugate deviation of the eyes that can be overcome by voluntary or reflexive activity, the score will be 1. If a patient has an isolated peripheral nerve paresis (CN III, IV, or VI), score a 1. Gaze is testable in all aphasic patients. Patients with ocular trauma, bandages, pre-existing blindness, or other disorder of visual acuity or fields should be tested with reflexive movements, and a choice made by the investigator. Establishing eye contact and then moving about the patient from side to side will occasionally clarify the presence of a partial gaze palsy., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: Normal [Normal gaze] 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 is not overcome by the oculocephalic maneuver.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0022], code=at0022, itemType=ELEMENT, level=4, text=Visual, description=Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No visual loss [No visual loss] 1: Partial hemianopia [Partial hemianopia] 2: Complete hemianopia [Complete hemianopia] 3: Bilateral hemianopia [Blind including cortical blindness.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0027], code=at0027, itemType=ELEMENT, level=4, text=Facial Palsy, description=Ask — or use pantomime to encourage — the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape, or other physical barriers obscure the face, these should be removed to the extent possible., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=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 [Complete paralysis Of one or both sides (absence of facial movement in the upper and lower face).] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0033], code=at0033, itemType=CLUSTER, level=4, text=Motor Arm, description=Motor Arm, comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=1..*, cardinalityText= , subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0033]/items[at0120], code=at0120, itemType=ELEMENT, level=5, text=Left Arm, description=The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN) and clearly write the explanation for this choice., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
1: Mild-to-moderate sensory loss [Patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched.] 2: Severe or total sensory loss [Patient is not aware of being touched in the face, arm, and leg.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0079], code=at0079, itemType=ELEMENT, level=4, text=Best Language, description=For this scale item, the patient is asked to describe what is happening in a picture, to name the items on a naming sheet, and to read from a list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=C_DV_ORDINAL, bindings=null, values=0: No aphasia [Normal. ] 1: Mild-to-moderate aphasia [Some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient’s response.] 2: Severe aphasia [All communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response.] 3: Mute, global aphasia [No usable speech or auditory comprehension.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0153], code=at0153, itemType=ELEMENT, level=4, text=Dysarthria, description=If patient is thought to be normal, an adequate sample of speech must be obtained by asking patient to read or repeat words from the attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated. Only if the patient is intubated or has other physical barriers to producing speech, the examiner should record the score as untestable (UN) and clearly write the explanation for this choice. Do not tell the patient why he/she is being tested., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CHOICE, bindings=null, values=Choice of:
1: Visual, tactile, auditory, spatial, or personal inattention [Or extinction to bilateral simultaneous stimulation in one of the sensory modalities.] 2: Profound hemi-inattention or extinction to more than one modality [Does not recognize own hand or orients to only one side of space.] , extendedValues=null], ResourceSimplifiedHierarchyItem [path=/data[at0001]/events[at0002]/data[at0003]/items[at0097], code=at0097, itemType=ELEMENT, level=4, text=Total Score, description=Records the sum of the points scored., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_COUNT, bindings=null, values=, extendedValues=null]], target=[], identities=[], items=[], relationships=[], credentials=[], context=[], contacts=[]}, topLevelItems={data=ResourceSimplifiedHierarchyItem [path=ROOT_/data[at0001]/events[at0002]/data[at0003], code=at0003, itemType=ITEM_TREE, level=2, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null], protocol=ResourceSimplifiedHierarchyItem [path=ROOT_/protocol[at0098], code=at0098, itemType=ITEM_TREE, level=0, text=null, description=null, comment=null, uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=0..1, cardinalityText=optional, subCardinalityFormal=0..*, subCardinalityText=Minimum of 0 items , dataType=ITEM_TREE, bindings=null, values=null, extendedValues=null]}, addHierarchyItemsTo=protocol, currentHierarchyItemsForAdding=[ResourceSimplifiedHierarchyItem [path=/protocol[at0098]/items[at0108], code=at0108, itemType=ELEMENT, level=2, text=*Time(pt), description=*Moment when the test was performed(pt), comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_DATE_TIME, bindings=null, values=Full Date and Time, extendedValues=null]], minIndents={}, termBindingRetrievalErrorMessage=null] |