there are many assessment scales used for measuring stroke severity , confined to either neurological , functional , or disability measures ( 2 - 4 ) . the national institutes of health stroke scale ( nihss ) is widely used to evaluate the severity of neurological deficit of stroke patients and predict the outcome of stroke in the clinical practice . it examines the level of consciousness , language function , neglect , visual field , eye movements , facial palsy , motor strength , sensory function , and coordination ( 5 , 6 ) . nurses in clinical department of neurology of split university hospital center use the categorization of patients ( cop ) according to epec et al . depending on the amount of necessary medical care , the nurse assesses the patients on a daily basis according to these factors , and depending on their needs classifies patients in a particular category on a scale from 1 to 4 ( the number of points for each factor is equal to the category in which the patient is placed ; category 2 = 2 points ) . depending on the total number of points determines the final category into which the patient will be placed ( category 1 = 16 - 26 points ; category 2 = 27 - 40 ; category 3 = 41 - 53 ; category 4 = 54 - 64 ) ( 7 ) . critical factors are : 
 hygiene , dressing , feeding , elimination , walking and standing , sitting , moving and turning ( each of these activities are individually estimated by the amount of help that nurse provides to the patient , depending on the need of using aids ; category 1 = independent patients ; category 4 = totally dependent ) ( 7),fall risk ( if there is no fall risk , the patient is classified into the category 1 ; if there is a fall risk , it is estimated using the morse fall scale ; category 2 = low risk = 0 - 24 points ; category 3 = moderate risk = 25 - 44 points ; category 4 = high risk = 45 or more points ) ( 7 , 8),pressure ulcer risk ( estimated by using the braden scale ; category 1 = no risk = 19 - 23 points ; category 2 = a risk is present = 15 - 18 points ; category 3 = moderate risk = 13 - 14 points = high risk = 10 - 12 points ; category 4 = very high risk = 9 points or less ) ( 7 , 9),state of consciousness ( category 1 = conscious patients , oriented in time and space ; category 2 = bemused patients ; category 3 = stupor , category 4 = pre - coma and coma ) ( 7 , 10),communication ( category 1 = no difficulties ; category 2 or 3 = dyslalia or gibberish depending on the intensity of difficulties ; category 4 = sensory or motor aphasia),education ( category 1 = oral or written instructions about new lifestyle adaptations ; category 2 = instructions , demonstrations , and verification of understanding ; category 3 = work with the guardian or family member ; category 4 = practice the patients and families knowledge and skills and verification of complete independence in the application of knowledge),vital signs ( category 1= vital signs are assessed 1 - 2 times daily ; category 2 = 3 - 4 times daily ; category 3 = 6 times daily ; category 4 = constant monitoring),specific procedures in the health care ( category 1 = the patient is self - contained ; category 2 = requires specific processes and minimal nursing ; category 3 = requires specific processes twice or more daily and a significant nursing ; category 4 = procedures are fully performed by nurse),understanding of the diagnostic methods ( category 1 = it is necessary to explain procedure , without specific preparation , or patient monitoring after procedure ; category 2 = explanation of procedures , psychic preparation of the patient and equipment , and nurse presence during the procedure ; category 3 = explanation of procedures , patient psychological and physical preparation , preparation of equipment , accompaniment , nurse participates in procedure , patient monitoring up to 12 hours after the procedure ; category 4 = patient requires the same actions as in the 3rd category except that patient monitoring takes 12 - 24 hours after the procedure),therapeutic procedures ( category 1 = oral therapy , inhalation , local therapy up to 4 times daily , and oxygen therapy ; category 2 = oral therapy , inhalation , or local therapy 5 or more times daily , injections ( i.c . , , i.v . ) , abdominal and pleural puncture , radiotherapy , self , group and family therapy ; category 3 = intermittent therapy ( enteral and parenteral ) , application of the 24 hour infusion in the order to maintenance of the central venous way , capd ; category 4 = continuous 24 hours therapy ( enteral and parenteral ) , i.v . cytostatic therapy , hemodialysis , plasmapheresis , biofiltration , continuous supervision over blood components transfusion , continuous supervision over blood - forming cells transplantation ) ( 7 ) . walking and standing , moving and turning ( each of these activities are individually estimated by the amount of help that nurse provides to the patient , depending on the need of using aids ; category 1 = independent patients ; category 4 = totally dependent ) ( 7 ) , fall risk ( if there is no fall risk , the patient is classified into the category 1 ; if there is a fall risk , it is estimated using the morse fall scale ; category 2 = low risk = 0 - 24 points ; category 3 = moderate risk = 25 - 44 points ; category 4 = high risk = 45 or more points ) ( 7 , 8) , pressure ulcer risk ( estimated by using the braden scale ; category 1 = no risk = 19 - 23 points ; category 2 = a risk is present = 15 - 18 points ; category 3 = moderate risk = 13 - 14 points = high risk = 10 - 12 points ; category 4 = very high risk = 9 points or less ) ( 7 , 9 ) , state of consciousness ( category 1 = conscious patients , oriented in time and space ; category 2 = bemused patients ; category 3 = stupor , category 4 = pre - coma and coma ) ( 7 , 10 ) , communication ( category 1 = no difficulties ; category 2 or 3 = dyslalia or gibberish depending on the intensity of difficulties ; category 4 = sensory or motor aphasia ) , education ( category 1 = oral or written instructions about new lifestyle adaptations ; category 2 = instructions , demonstrations , and verification of understanding ; category 3 = work with the guardian or family member ; category 4 = practice the patients and families knowledge and skills and verification of complete independence in the application of knowledge ) , vital signs ( category 1= vital signs are assessed 1 - 2 times daily ; category 2 = 3 - 4 times daily ; category 3 = 6 times daily ; category 4 = constant monitoring ) , specific procedures in the health care ( category 1 = the patient is self - contained ; category 2 = requires specific processes and minimal nursing ; category 3 = requires specific processes twice or more daily and a significant nursing ; category 4 = procedures are fully performed by nurse ) , understanding of the diagnostic methods ( category 1 = it is necessary to explain procedure , without specific preparation , or patient monitoring after procedure ; category 2 = explanation of procedures , psychic preparation of the patient and equipment , and nurse presence during the procedure ; category 3 = explanation of procedures , patient psychological and physical preparation , preparation of equipment , accompaniment , nurse participates in procedure , patient monitoring up to 12 hours after the procedure ; category 4 = patient requires the same actions as in the 3rd category except that patient monitoring takes 12 - 24 hours after the procedure ) , therapeutic procedures ( category 1 = oral therapy , inhalation , local therapy up to 4 times daily , and oxygen therapy ; category 2 = oral therapy , inhalation , or local therapy 5 or more times daily , injections ( i.c . , s.c . , i.v . ) , abdominal and pleural puncture , radiotherapy , self , group and family therapy ; category 3 = intermittent therapy ( enteral and parenteral ) , application of the 24 hour infusion in the order to maintenance of the central venous way , capd ; category 4 = continuous 24 hours therapy ( enteral and parenteral ) , i.v . cytostatic therapy , hemodialysis , plasmapheresis , biofiltration , continuous supervision over blood components transfusion , continuous supervision over blood - forming cells transplantation ) ( 7 ) . the aim of this study was to demonstrate that there is a positive correlation between the cop and nihss in is patients . the study was conducted at the clinical department of neurology of split university hospital center . a diagnosis of stroke was confirmed after both a careful critical neurological examination and a positive neuroimaging result using computerized tomography ( ct ) or magnetic resonance imaging ( mri ) according to the international classification of diseases , 10th revision . clinical data included age , gender , nihss scores ( at admission and at discharge ) , cop ( at admission and at discharge ) , and duration of the hospitalization . the inclusion criteria were medical diagnosis of is definitely diagnosed by ct or mri scan , and the arrival of the patient in the hospital within 24 h of stroke onset . the exclusion criteria for this study were the presence of other types of cerebrovascular disease ( intracranial hemorrhage , subarachnoid hemorrhage , transient ischemic attack , cerebral aneurysm , cerebrovascular malformation ) , and comorbidities with severe diseases such as cancer , inflammatory diseases ( rheumatoid arthritis ) , serious chronic diseases ( heart or kidney failure ) , and patients with mental disorder or severe dementia . if participants were unable to communicate , written consent was obtained from their legal guardians . the data were analyzed by spss statistical software version 23.0 ( spss inc , chicago , usa ) . categorical variables were expressed as numbers ( percentage ) and ordinal variables as a median . we used the 2 test for independent samples to compare categorical variables and mann - whitney u - test for age distribution by gender . dependence between the groups was analyzed by spearman s rank correlation coefficient ( 95% ci ) . participants with a fatal outcome 130 ( 35% ) and those without complete documentation 244 ( 65% ) were excluded . the remaining 325 participants were included ( median age 77 years , min - max : 37 - 95 years ) . there was a total of 169 ( 52% ) males ( median age 73 years , min - max : 37 - 90 years ) and 156 ( 48% ) females ( median age 79 years , min - max : 48 - 95 years ) . median of nihss scores at admission is higher in females than in males for 2 ( z=4.45 , p<0.001 ) and at discharge is higher for 2 ( z = 4.1 , p<0.001 ) . median of cop at admission is higher in females than in males for 1 ( z=4.7 , p<0.001 ) and at discharge is the same ( z=4.7 , p<0.001 ) ( table 1 ) . number ( % ) of participants according to the qualitative variables and median ( min - max ) of quantitative variables at admission and discharge , total and in relation to gender . * mann - whitney u - test ; * * wilcoxon test . in 223 ( 69% ) participants the value of nihss score at the discharge is decreased compared to the value at the admission , in 39 ( 12% ) participants is increased , and in 63 ( 19% ) remained the same ( z=9.4 , p<0.001 ) . in 83 ( 25.5% ) participants the value of cop at discharge is decreased compared to the value at the admission , in 20 ( 6% ) participants is increased , and in 222 ( 68.5% ) remained the same ( z=5.9 , p<0.001 ) . in 125 ( 74% ) males the value of nihss score at discharge is decreased compared to the value at the admission , in 10 ( 6% ) is increased , and in 34 ( 20% ) remained the same ( z=8.6 ; p<0.001 ) . in 39 ( 23% ) males the value of cop at discharge is decreased compared to the value at the admission , in 7 ( 4% ) is increased , while in 123 ( 73% ) remained the same ( z=4.5 ; p<0.001 ) . in 98 ( 63% ) females the value of nihss score at discharge is decreased compared to the value at the admission , in 29 ( 18.5% ) is increased , and in 29 ( 18.5% ) remained the same ( z=4.9 , p<0.001 ) . in 44 ( 28% ) females the value of cop at discharge is decreased compared to the value at the admission , in 13 ( 8% ) is increased , and in 99 ( 64% ) of them remained the same ( z=4.0 , p<0.001 ) . there is a statistically significant correlation between the nihss score at admission and cop at admission ( =0.717 ; p<0.001 ) . nihss score is statistically significant , but poorly associated to duration of the hospitalization ( =0.240 ; p<0.001 ) and age ( =0.149 ; p=0.007 ) . cop is statistically significant associated to duration of the hospitalization ( =0.314 ; p<0.001 ) and age ( =0.173 ; p<0.002 ) . duration of the hospitalization and age are not statistically significant associated ( =-0.099 ; p=0.074 ) ( table 2 ) . there is a statistically significant correlation between the nihss score at discharge and cop at discharge ( =0.762 ; p<0.001 ) . nihss score is statistically significant , but poorly associated to duration of the hospitalization ( =0.287 ; p<0.001 ) and age ( =0.138 ; p=0.013 ) . cop is statistically significant , but poorly associated to duration of the hospitalization ( =0.321 ; p<0.001 ) and age ( =0.161 ; p<0.004 ) ( table 3 ) . correlation of research variables at discharge : spearmans rho (  ) . by multiple regression analysis in which the dependent variable was duration of the hospitalization , and the independent variables were gender , age , nihss score and cop we obtained that these independent variables are predictors of duration of the hospitalization ( f=14.6 , p<0.001 ) . the change in duration of the hospitalization is by 15.4% explained by gender , age , nihss score , and cop , and all other changes are due to predictors that are not included in these analyses ( table 4 ) . stroke is a kind of disease with the characteristics of obvious stage change of symptoms ( 1 ) . a comprehensive and precise prognosis scale of is still needs to be further developed ( 5 ) . the present study showed that nihss score ( at admission and at discharge ) in is patients was associated with cop , which is associated with a higher demand for health care . however , searching the literature we did not find any study that examines the connection between these two scales . the nihss is a valid , efficient , and reliable measure of the patient s status after a stroke and in assessing outcome after treatment . among neurologists and nurses the nihss contains parameters for observing changes in the patient s neurological status and measuring stroke severity ( 12 ) . in contrast to nihss score cop contains much more data about the total physical condition , affecting the prognosis and outcome of is patients ( 7 ) . there is a significant association of nihss scores and vessel occlusions , and increased baseline nihss score is associated with an increased risk of neurological and medical complications ( 5 , 6 ) . it is highlighted that , the larger the number of patient needs are affected , the greater the urgency to plan care , as the systemization of actions aims for the organization , effectiveness and validity of care delivery ( 13 ) . taking into account our results , is patients with higher nihss score require a higher nursing level due to poor total somatic condition ( e.g. increasing the likelihood of developing pressure ulcers , poorer physical activity , increasing dependence on nurse s assistance  ) . our findings underscore the importance of using the nihss not only as a measure of stroke severity , but also as part of the assessment of needs for health care that are in correlation with cop . stroke is a complex disease that requires the efforts and skills of all members of the multidisciplinary team ( 12 ) . even in specialized stroke units , up to 63% of patients experience 1 or more complications after is ( 14 ) . medical and nursing management are often responsible for the coordination of care throughout the continuum and both are focus on the prevention of subacute complications of stroke ( 12 ) . as for interventions related with complication and trauma prevention , nurses should enhance the maintenance of the normal function , preventing complications and traumas , assessing patient s basic needs and guaranteeing the patient s best condition to benefit from rehabilitation ( 15 ) . our data were obtained from a single hospital setting and therefore may not be generalizable to other settings . our results are also obtained from a retrospective analysis in a small sample size , and therefore prospective validation is required before nihss score can be considered as a predictor of health care needs . despite some methodological limitations , the present study shows that , in is patients , higher nihss score is associated with an increased cop which predict higher health care needs . our findings suggest that nihss assessment may be a useful approach to predict the need for health care , because it can alert the physician to the anticipated risk of somatic and neurological complications in an individual patient and can thus affect early decisions about further surveillance and diagnostics .
introduction : scientific guidelines recommend the national institutes of health stroke scale ( nihss ) for ischemic stroke ( is ) assessment . in clinical department of neurology of split 
 university hospital center nurses use the categorization of patients ( cop ) according to individual needs for health care.aim:the aim of this study was to demonstrate that there is a positive correlation between the cop and the nihss in is patients.methods:we analyzed nihss scores and cop findings in 325 participants ( median age 77 years , min - max : 37 - 95 years ) with acute iss.results:there is a statistically significant correlation between the nihss score at admission and cop at admission ( =0.717 ; p<0.001 ) . 
 there is a statistically significant correlation between the nihss score at discharge and cop at discharge ( =0.762 ; p<0.001 ) . 
 median of nihss scores at admission is higher in females than in males for 2 ( z=4.45 , p<0.001 ) and at discharge is higher for 2 ( z = 4.1 , p<0.001 ) . 
 median of cop at admission is higher in females than in males for 1 ( z=4.7 , p<0.001 ) and at discharge is the same ( z=4.7 , p<0.001).conclusion : there is a significant association of nihss scores and cop in is patients . 
 this association exists at admission and at discharge from the hospital .