411-STROKE
|
SCALE |
ANSWERS,
|
LATEST |
UPDATED|
2022/23 |
, Attempt |History
Hernandez, |Delmy
01 |NIHSSEnglish |Group |AV3 | 1st |Certification
Date Result
3/3/2018 |4:12:38 |AM Passed 89 |of |90 | (98.89 |%) View |Responses
Patient | 1
Topic Question Answer Grade
Level |of 1a. |Level |of 0 |= |Alert; |keenly |responsive Correct
|Consciousness |Consciousness: |The
|investigator |must
|choose |a |response,
|even |if |a |full
|evaluation |is
|prevented |by |such
|obstacles |as |an
|endotracheal |tube,
|language |barrier,
|orotracheal
|trauma/bandages. |A |3
|is |scored |only |if |the
|patient |makes |no
|movement |(other |than
|reflexive |posturing) |in
|response |to |noxious
|stimulation.
LOC |Questions 1b. |LOC |Questions: |The 0 |= |Answers |both |questions Correct
patient |is |asked |the |correctly
|month |and |his/her
|age. |The |answer |must
|be |correct |there |is |no
|partial |credit |for |being
|close. |Aphasic |and
|stuporous |patients
|who |do |not
|comprehend |the
|questions |will |score |2.
|Patients |unable |to
|speak |because |of
|endotracheal
|intubation, |orotracheal
|trauma, |severe
|dysarthria |from |any
|cause, |language
|barrier |or |any |other
|problem |not |secondary
|to |aphasia |are |given |a
|1. |It |is |important |that
|only |the |initial |answer
|be |graded |and |that
|the |examiner |not
|"help" |the |patient |with
|verbal |or |nonverbal
|cues.
LOC |Commands 1c. | LOC | Commands: The |patient |is |asked |to |open |and |close |the
,|eyes |and |then |to |grip 0 |= |Performs |both |tasks |correctly |Correct
|and
, | occasionally
release |the |nonparetic
|hand. |Substitute
|another |one |step
|command |if |the |hands
|cannot |be |used. |Credit
|is |given |if |an
|unequivocal |attempt |is
|made |but |not
|completed |due |to
|weakness. |If |the
|patient |does |not
|respond |to |command,
|the |task |should |be
|demonstrated |to |them
|(pantomime) |and
|score |the |result |(i.e.,
|follows |none, |one |or
|two |commands).
|Patients |with |trauma,
|amputation, |or |other
|physical |impediments
|should |be |given |suitable
|onestep |commands.
Only |the |first | attempt |is
scored.
Best |Gaze 2. |Best |Gaze: |Only
|horizontal |eye
|movements |will |be
|tested.Voluntary |or
|reflexive
|(oculocephalic) |eye
|movements |will |be
|scored |but |caloric
|testing |is |not |done. |If
|the |patient |has |a
|conjugate |deviation |of
|the |eyes |that |can |be
|overcome |by
|voluntary |or |reflexive
|activity, |the |score |will
|be |1. |If |a |patient |has
|an |isolated |peripheral
|nerve |paresis |(CN |III,
|IV |or |VI) |score |a |1.
|Gaze |is |testable |in |all
|aphasic |patients.
Patients |with |ocular
trauma, |bandages, |pre
|existing |blindness |or
|other |disorder |of
|visual |acuity |or |fields
|should |be |tested |with
|reflexive |movements
|and |a |choice |made
|by |the |investigator.
Establishing |eye |contact
|and |then |moving
|about |the |patient |from
|side |to |side |will