Neurological Concepts in Critical Care

NIH Stroke Scale

nursebob 07/25/10

1.a. Level of Consciousness

SCORE ____

0 Alert
1 Not alert, but arousable with minimal stimulation.
2 Not alert, requires repeated stimulation to attend.
3 Coma
1.b. Ask patient the month and their age:

SCORE____

0 Answers both correctly
1 Answers one correctly
2 Both incorrect
1.c. Ask patient to open and close eyes

SCORE____

0 Obeys both correctly
1 Obeys one correctly
2 Both incorrect
2. Best gaze
(only horizontal eye movement):

SCORE____

0 Normal1 Partial gaze palsy2 Forced deviation
3. Visual Field testing:

SCORE____

0 No visual field loss
1 Partial hemianopia
2 Complete hemianopia
3 Bilateral hemianopia
(blind including cortical blindness)
4. Facial Paresis (Ask patient to show teeth or raise eyebrows and close eyes tightly):

 

SCORE:____

0 Normal symmetrical movement
1 Minor paralysis
(flattened nasolabial fold, asymmetry on smiling)
2 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):

Right arm ____
Left arm _____

SCORE____

0 Normal
(extends arems 90 (or 45) degrees for 10 seconds without drift)

1 Drift
2 Some effort against gravity
3 No effort against gravity4 No movement

9 Untestable (Joint fused or limb amputated)
6. Motor Function - Leg (right and left):
Right leg ____
Left leg _____

SCORE____

0 Normal (hold leg 30 degrees position for 5 seconds)
1 Drift
2 Some effort against gravity
3 No effort against gravity
4 No movement

9 Untestable (Joint fused or limb amputated)
7. Limb Ataxia

SCORE ____

0 No ataxia
1 Present in one limb
2 Present in two limbs
8. Sensory
(Use pinprick to test arems, legs,trunk and face -- compare side to side)

SCORE____

0 Normal
1 Mild to moderate decrease in sensation

2 Severe to total sensory loss
9. Best Language
(describe picture, name items,
read sentences)

SCORE____

0 No aphasia
1 Mild to moderate aphasia
2 Severe aphasia

3 Mute
10. Dysarthria (read several words)

SCORE____

0 Normal articulation
1 Mild to moderate slurring of words
2 Near unintelligible or unable to speak
9 Intubated or other physical barrier
11. Extinction and inattention

SCORE____

 

0 Normal
1 Inattention or extinction to bilateral simultaneous stimulation
in one of the sensory modalities

2 Severe hemi-inattention or hemi-inattention to more than one modality
TOTAL SCORE _____  

REFERENCE: NIH Stroke Assessment, US Government.

All comments and questions about content at this site should be sent to Nurse Bob
There have been Visitors to this page.
Return to Nurse Bob's Page