Nih Stroke Scale Sheet
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1
2NIH STROKE SCALE SHEET (Circle the Patient’s Score)
0 =
Alert, keenly responsive
0 =
Absent, global aphasia, complete hemiplegia
LOC
Limb Ataxia
Out of Propor-
1 =
Not alert, but arousable by minor stimulation to
1 =
Present in 1 limb
tion to
obey, answer, or respond
2 =
Present in 2 limbs
Weakness (test
2 =
Not alert, requires repeated stimulation to
UN = Post-angio maintain straight leg, amputation, joint
both arms FTN
attend, pain to move
fusion, explain:____________________________________
legs HTS)
3 =
Responds with reflex motor, posturing,
unresponsive, not movement, etc.
0 =
Answers both questions correctly
Don’t test on hands/feet
Month
Sensory on
Age
Face/Arms/Legs
1 =
Answers one question correctly, intubated but
0 =
Normal, no sensory loss
(use pin or
follows command
1 =
Mild to moderate sensory loss, can tell touch
noxious)
2 =
Answers neither question correctly, aphasic,
2 =
Severe to total sensory loss, not aware of touch,
stuporous, coma
coma, or quadriplegic
0 =
Performs both tasks correctly without
0 =
Normal, no aphasia
Open/Close
Best Language
coaching
Eyes
(describe
1 =
Mild to moderate aphasia, can be understood
Open/Close
picture, name
1 =
Performs one task correctly, even if weak
2 =
Severe aphasia, much is not understood, excess
Good Hand
objects, read
2 =
Performs neither task correctly
listener work
sentences)
3 =
Mute, global aphasia, no usable speech or
auditory comprehension, follows no 1 step
0 =
Normal
Best Gaze
commands, coma
Horizontal
1 =
Partial gaze palsy, can be overcome by finger
Alternate method if unable to read: repeat words/
(voluntary or
tracking/head turning
sentences, object recognition after feeling object
Doll’s)
2 =
Forced deviation or total gaze paresis, not
in hand
overcome by the oculocephalic maneuver
0 =
Normal
Dysarthria
0 =
Normal, no visual loss, or regards/looks at
Visual Fields
(clarity of
1 =
Mild to moderate dysarthria, some slurring, speech
moving fingers
(upper, lower
articulation,
understood
quadrants)
1 =
Partial (upper/lower quadrantopia) hemianopia,
read or repeat
2 =
Severe, so slurred to be unintelligible
visual extinction
words)
UN = Intubated, or other physical barrier explain:_______
2 =
Complete hemianopia
If patient is aphasic, judge only the spontaneous
3 =
Bilateral hemianopia, blindness
w o r d s
0 =
No abnormality
0 =
Normal, symmetrical movement
Facial Palsy
Extinction or
(show teeth,
Inattention,
1 =
Personal inattention or extinction to bilateral
1 =
Minor asymmetry,
nasolabial fold
raise eye-
Neglect (test
stimuli in any one of the senses (vision, tactile,
2 =
Partial paralysis lower face
brows, close
face and arms
auditory, spatial or personal )
3 =
Complete paralysis 1 or both sides, upper/lower
eyes,use
with bilateral
2 =
Profound inattention or extinction to more than
face (absence of facial movement in the upper
simultaneous
noxious
one sense, may not recognize own hands or
and lower face)
stimulation)
stimuli)
orients to only one side of space
0 =
No drift; limb holds 90 (or 45) degrees for full 10 seconds.
1 =
Drift; limb holds 90 (or 45) degrees, but drifts down before
full 10 seconds; does not hit bed or other support.
2 =
Some effort against gravity; limb cannot get to or
TOTAL NIH STROKE SCALE SCORE _____________________
maintain (if cued) 90 (or 45) degrees, drifts down to bed,
(Don’t count any UN’s in score)
but has some effort against gravity.
3 =
No effort against gravity; limb falls.
4 =
No movement.
DATE _____________________ TIME ____________________
UN = Amputation or joint fusion, explain:_____________________
5a. Left Arm
0
1
2
3
4
UN
5b. Right Arm
0
1
2
3
4
UN
EXAMINER ______________________________________________
0 =
No drift; leg holds 30-degree position for full 5 seconds.
MD or RN (NIH Stroke Scale trained)
1 =
Drift; leg falls by the end of the 5-second period but does
not hit bed.
Please check appropriate box to indicate time this NIHSS completed:
2 =
Some effort against gravity; leg falls to bed by 5
Admit (or at time of Code 3 Stroke initiated)
seconds, but has some effort against gravity.
24 hours
Discharge
3 =
No effort against gravity; leg falls to bed immediately.
4 =
No movement.
PLACE IN H&P/CONSULT SECTION OF CHART.
UN = Amputation or joint fusion, explain:_____________________
6a. Left Leg
0
1
2
3
4
UN
6b. Right Leg
0
1
2
3
4
UN
LABEL
SACRED HEART MEDICAL CENTER
Spokane, Washington
NIH STROKE SCALE
9/04
Approved by Neuroscience Service Line 9/17/04
#Z04570
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