NIH Stroke Scale Scoring Sheet

Notify physician for change in NIHSS >4pts or mNIHSS >2pts Patient Identification
Date:
Time:
Shaded areas indicate Modified Scale Initials:
1a. Level of Alert (or awakens easily and stays awake) 0
Consciousness(LOC) Drowsy (Responds to minor stim. but falls back asleep) 1
Arousal Status Obtunded (Responds only to deep pain or vigorous stim) 2
Comatose (No response) 3
1b. LOC- Questions Both questions answered correctly 0
Month? Age? One question answered correctly 1
Neither question answered correctly 2
1c. LOC Commands Both commands performed correctly 0
Opens/closes eyes One command performed correctly 1
Opens/closes hands Neither command performed correctly 2
2. Eye Movements: Normal 0
Horizontal eye Mild gaze paralysis (can bring eyes only over to midline) 1
movements Complete gaze paralysis (deviated & unable to bring eyes over) 2
3. Visual fields: Normal 0
Sees objects in Partial hemianopia (upper OR lower quadrant) 1
Four quadrants Complete hemianopia (upper AND lower quadrants) 2
Bilateral hemianopia (total blindness) 3
4. Facial: Normal 0
Facial movements Minor paralysis (flattening of nasolabial folds) 1
Partial paralysis (near or total paralysis lower face) 2
Complete paralysis (Of upper and lower face) 3
5a. Motor Left Arm Normal (No drift at all) 0
Hold arm straight out Drift (Drifts downward but NOT to bed before 10 sec.) 1
from chest Drifts to bed within 10 sec 2
Movement, but not against gravity 3
Complete paralysis (No movement at all) 4
Amputation or joint fusion (N/A)
5b. Motor Right Arm Normal (No drift at all) 0
Hold arm straight out Drift (Drifts downward but NOT to bed before 10 sec.) 1
from chest Drifts to bed within 10 sec 2
Movement, but not against gravity 3
Complete paralysis (No movement at all) 4
Amputation or joint fusion (N/A)
6a. Motor Left leg Normal (No drift at all) 0
Keep leg off bed Drift (Drifts downward but NOT to bed before 5 sec.) 1
Drifts to bed within 5 sec 2
Movement, but not against gravity 3
Complete paralysis (No movement at all) 4
Amputation or joint fusion (N/A)
6b. Motor Right leg Normal (No drift at all) 0
Keep leg off bed Drift (Drifts downward but NOT to bed before 5 sec.) 1
Drifts to bed within 5 sec 2
Movement, but not against gravity 3
Complete paralysis (No movement at all) 4
Amputation or joint fusion (N/A)
7. Limb Ataxia Absent (no ataxia, OR pt cannot move arm/leg) 0
Finger-Nose Present in one limb 1
Heel-Knee-Shin Present in two or more limbs 2
(is absent if patient cannot understand or is too weak to do)
8. Sensory Normal, no sensory loss 0
Hemisensory loss: (Test Mild to moderate loss 1
on face, arm & thigh) Severe to total sensory loss (unaware of being touched) 2
9. Language/Aphasia Normal ability use words and follow commands 0
Repetition & Mild to Moderate (Repeats / names with some difficulty) 1
Comprehension Severe Aphasia (very few words correct or understood) 2
Today is a bright sunny Mute (no ability to speak or understand at all) 3
day
10. Dysarthria (slurred) Normal 0
Speech clarity Mild to moderate slurred speech (some or most) 1
(slurring) Severe (unintelligible - none understandable) 2
Intubated or other physical barrier (N/A)
11. Neglect No abnormality 0
Ignores touch or vision Mild (either visual or tactile partial neglect) 1
to one side Profound (Visual and tactile complete neglect) 2
Total Score 0 = Best, 42 = Worst
Initials Nurse Signature Initials Nurse Signature

MR Form U3104-100-SWRR 9/13 All N/As need to be explained in documentation.