There have been
Neurological Concepts in Critical Care
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 ____
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.
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