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Stroke Scale PDF 2 PDF

The document outlines a National Institutes of Health stroke scale used to evaluate and score patients experiencing a stroke. It lists 11 categories to assess including level of consciousness, visual fields, facial palsy, limb movement, sensory, language, and neglect. Scores are totaled to determine stroke severity ranging from no symptoms to severe stroke.

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242 views2 pages

Stroke Scale PDF 2 PDF

The document outlines a National Institutes of Health stroke scale used to evaluate and score patients experiencing a stroke. It lists 11 categories to assess including level of consciousness, visual fields, facial palsy, limb movement, sensory, language, and neglect. Scores are totaled to determine stroke severity ranging from no symptoms to severe stroke.

Uploaded by

Sisca Chearz
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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NATIONAL INSTITUTES OF HEALTH

Stroke Scale
CATEGORY STROKE SCALE SCORE

1a. Level of consciousness 0 1 2 3


Alert, Drowsy, etc Alert Drowsy Stuporous Coma

1b. LOC Questions 0 1 2


Month, age Answers both Answers one Incorrect
correctly correctly

1c. LOC Commands 0 1 2


Open/close eyes, make a fist & let go Obeys both Obeys one Incorrect
correctly correctly

2. Best Gaze
0 1 2
Eyes open - pt follows examiner’s
Normal Partial gaze Forced
fingers or face. palsy deviation

3. Visual
0 1 2 3
Introduce visual stimulus/threat to pt’s visual
field quadrants. Cover 1 eye and hold up No visual Partial Complete Bilateral
loss hemianopsia hemianopsia hemianopsia
fingers in all 4 quadrants.

4. Facial Palsy 0 1 2 3
Show teeth, raise eyebrows and squeeze
Normal Minor Partial Complete
eyes tightly shut.

5.a Motor Arm - Left 0 1 2 3 4


Elevate extremity to 90 degrees and score No Drift Drift Can’t resist No effort No
drift/movement. Count to 10 out loud and use gravity against gravity Movement

fingers for visual cue. NT = Amputation, joint fusion

5.b Motor Arm - Right 0 1 2 3 4


Elevate extremity to 90 degrees and score No Drift Drift Can’t resist No effort No
gravity against gravity Movement
drift/movement. Count to 10 out loud and use
fingers for visual cue. NT = Amputation, joint fusion

TOTAL =
6.a Motor Leg - Left 0 1 2 3 4
Elevate extremity to 30 degrees and score No Drift Drift Can’t resist No effort No
drift/movement. Count to 5 out loud and use gravity against gravity Movement

fingers for visual cue. NT = Amputation, joint fusion

6.b Motor Leg - Right 0 1 2 3 4


Elevate extremity to 30 degrees and score No Drift Drift Can’t resist No effort No
drift/movement. Count to 5 out loud and use gravity against gravity Movement

fingers for visual cue. NT = Amputation, joint fusion

7. Limb Ataxia 0 1 2
Finger to nose, heal down shin Absent Present in Present in
one limb two limbs

8. Sensory
0 1 2
Pin prick to face, arms, trunk, and legs -
Normal Partial loss Severe Loss
compare sharpness side to side

9. Best Language
Name items, describe picture, and read
0 1 2 3
sentences. Don’t forget glasses if they No aphasia Mild to Severe Mute
moderate aphasia
normally wear them. aphasia

10. Dysarthria 0 1 2
Normal Mild to Near to
Evaluate speech clarity by pt reading or articulation moderate unintelligible
dysarthria or worse
repeating words on list.
NT = Intubated or other physical barrier

11. Extinction and Inattention


Use information from prior testing or double 0 1 2
simultaneous stimuli testing to identify No neglect Partial Complete
neglect neglect
neglect. Face, arms, legs, and visual fields.

NT = Not Testable acceptable as noted above

Score Stroke Severity

0 No stroke symptoms
1-4
5-15
Minor stroke
Moderate stroke
TOTAL =
16-20 Moderate to severe stroke
21-42 Severe stroke

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