2024年7月19日 · Get the NIH stroke scale, a validated tool for assessing stroke severity, in PDF or text version, and the stroke scale booklet for healthcare professionals.

National Institutes of Health Stroke Scale (NIHSS) Score Instructions BaselineScale Definition Date/Time 24 Hrs Post TPA Discharge Date/Time 1a. LOC 0 = Alert keenly responsive 1 = Not Alert but arousable by minor stimulation to obey, answer, respond 2 = Not Alert; requires repeat stimulation, obtunded, requires strong stimuli

Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not …

Finger-to-nose, heel-to-shin. Score only if not caused by weakness. 0= Normal (comatose) 1= Clumsy in one limb 2= Clumsy in two limbs *Score “0” if extremity weakness present and pt. cannot appropriately perform the exam. 8. Sensation (feeling) (Pin prick face, arm, leg – compare sides) 0= Normal 1= Decreased sensation

NIH Stroke Scale Reference booklet for health professionals who administer the NIH Stroke Scale \(NIHSS\) to stroke patients.

• Can only score items 2 & 3 (oculocephalic move and blink to threat) • Remaining items receive the highest score except for 7 (ataxia). Ataxia receives a zero since it

A score of 2, “severe or total,” should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will therefore probably score 1 or 0. The patient with brain stem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2 ...

Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not …

• Only score if patient is able to move the limb, and the precision of movement is abnormal out of proportion to weakness.

The "Quick & Easy" NIHSS Authored by: Judith Spilker, RN, BSN, Dept. of Emergency Medicine & Laura R. Sauerbeck, RN, BSN, Dept. of Neurology, University of Cincinnati.