NIH stroke scale Questions and Answers Scored A+

NIH stroke scale Questions and Answers Scored A+ 1a LOC 0: alert 1: not alert; aroused with minor verbal stimulation 2: not alert; requires strong or painful stimulation 3: reflex movements only or totally unresponsive 1b LOC questions What month is it? What's your age? 0: answers both questions correctly 1: answers one question 2: answers neither question correctly 1c LOC COMMANDS -close your eyes, now open -make a fist with your hand (can show pt to make a fist) Give credit if attempt is made but not completed do to weakness 0: both tasks performed correctly 1: performs one task correctly 2: neither task is performed correctly 2 BEST GAZE -have pt track your finger/examiners face 0: normal (if pt has strabismus but eye leaves midline and looks r and l, then normal) 1: partial gaze palsy (if there's conjugate deviation of eyes that can be overcome by voluntary or reflexive activity, abducens palsy) 2: forced deviation (not overcome by the oculocephalic maneuver) 3 VISUAL FIELDS -tell pt you'll be testing peripheral vision and to look at your nose -have pt count number of fingers you're holding up in all 4 quadrants -cover R eye, ask pt how many fingers they see in all 4 quadrants -cover L eye, repeat 0: no visual loss (if pt confused but looks at fingers, score 0) 1: partial hemianopia (patient recognizes no visual stimulus in ONE specific quadrant) 2: complete hemianopia (patient recognizes no visual stimulus in ONE HALF of the visual field 3: bilateral hemianopia (blind including cortical blindness) 4 FACIAL PALSY -encourage pt to show teeth -raise eyebrows -squeeze eyes shut -for pt not following commands, look at grimace with noxious stimuli 0: normal 1: minor paralysis 2: partial paralysis (paralysis of lower face) 3: complete paralysis 5 MOTOR ARM - extend arms 90 degrees if pt is sitting or 45 degrees if pt is supine, palms must be down, one arm at a time -count 10 seconds with release of a limb 0: no drift or no drift after initial dip for 10 sec 1: drift before full 10 sec 2: some effort against gravity but arm cannot maintain proper position and drifts down 3: arm falls, no effort against gravity 4: no voluntary movement (any movement at all like shoulder shrug will lower score to 3) if pt unresponsive, automatically a 4 6 MOTOR LEG -test leg supine position at 30 degrees -score a drift if the leg falls before 5 sec -count with your fingers in front of pt -begin with non paretic limb first 0: no drift 1: drift 2: some effort against gravity but leg falls 3: no effort against gravity (pt makes small movements like hip flexion or adduction) 4: no movement 7 LIMB ATAXIA -assessment for unilateral cerebellar lesion, checking coordination -finger nose finger (both sides) -heel shin test (move one heel down and up the shin on opposite leg, both sides) 0: normal coordination, absent (if pt unresponsive, score 0) 1: present in one limb 2: present in two limbs 8 SENSORY -series of pin pricks in all 4 limbs, trunk, face, pt can leave eyes open, observe for grimace in unresponsive pt with noxious stimuli (squeezing fingers, pressing on nail beds) -ask which side feels a sharper poke -don't test hands or feet in case of neuropathy 0: normal 1: mild or moderate loss of sensation 2: severe or total sensory loss (bilateral loss of sensation, brain stem stroke)