NIH STROKE SCALE, Summaries of Nursing

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NIH STROKE SCALE

1.a. Level of Consciousness :

0

00

0 Alert 1 11

1 Not alert, but arousable with minimal stimulation

2222 Not alert, requires repeated stimulation to attend 3333 Coma

1.b. Ask patient the month and their age:

0000 Answers both correctly 1111 Answers one correctly 2222 Both incorrect

1.c. Ask patient to open and close eyes

and grip and release non-paretic hand.

0

00

0 Obeys both correctly 1 11

1 Obeys one correctly 2 22

2 Both incorrect

2. Best gaze (only horizontal eye

movement):

0000 Normal 1111 Partial gaze palsy 2222 Forced deviation

3. Visual Field testing:

0000 No visual field loss 1111 Partial hemianopia

2222 Complete hemianopia 3333 Bilateral hemianopia (blind including cortical blindness)

4. Facial Paresis (ask the patient

to show teeth or raise eyebrows

and close eyes tightly)

0000 Normal symmetrical movement 1111 Minor paralysis

2222 Partial paralysis (total or near total paralysis of lower face)

3 Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)

5. Motor Function - Arm (right and left):

Rt arm Lt arm

0000 Normal (extends arms 90 (or 45) degrees for 10 seconds without drift)

1111 Drift 2222 Some effort against gravity 3333 No effort against gravity

4444 No movement 9999 Untestable (Joint fused or limb amputated)

6. Motor Function - Leg (right and left):

Rt leg Lt leg

0000 Normal (hold leg 30 degrees position for 5 seconds)

1111 Drift 2222 Some effort against gravity 3333 No effort against gravity

4444 No movement 9999 Untestable (Joint fused or limb amputated)

7. Limb Ataxia:

0 No ataxia 1 Present in one limb 2 Present in two limbs

8. Sensory (Use pinprick to test arms,

legs, trunk and face -- compare side to

side):

0000 Normal 1111 Mild to moderate decrease in sensation 2222 Severe to total sensory loss

9. Best Language (describe picture, name

items, read sentences)

0000 No aphasia 1111 Mild to moderate aphasia

2 Severe aphasia 3 33

3 Mute

10. Dysarthria (read several words):

SCORE

0

00

0 Normal articulation 1 11

1 Mild to moderate slurring of words

2 Near unintelligible or unable to speak 9 99

9 Intubated or other physical barrier

11. Extinction and inattention:

0000 Normal

1111 Inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities

2222 Severe hemi-inattention or hemi-inattention to more than one modality

TOTAL SCORE

Ad 2hrs 24hrs 7days D/C 90days

Name DOB PID

"Cookie-Theft" Image for Extinction and Inattention item (No# 9 & 11)

Image for ‘Best Language Test’ (No# 9)

"Reading Sentences" Image for Best Language item (No# 9)

You know how.

Down to earth.

I got home from work.

Near the table in the dining room.

They heard him speak on the radio

last night.

"Reading Words" Image for Dysarthria item (No# 10)

MAMA

TIP-TOP

FIFTY-FIFTY

THANKS

HUCKLEBERRY

BASEBALL PLAYER

CATERPILLAR