Acute Stroke Response Team Form
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1
Today’s Date: __________________
DATE/TIME LAST KNOWN WELL_________________
NIH Stroke Scale
Category
Description
Time:
Plan of Care Discussed:
Score
Score
- ED Physician/PA _____________________
Level of
0=Alert
Consciousness
1=Not Alert but arousable by mild stimulation
2=Not alert; Requires repeated stimulation to attend
- Other Hospital: _______________________
3=Responds only with reflex motor/or autonomic
reflex or unresponsive
Level of
0= Answers both month and age correctly
IV tPA - Treatment Plan
1=Answers one question correctly
Consciousness
Contraindicated per Dr._____________
Questions
2=Answers neither question correctly
> 3 hour window
LOC-Commands
0= Performs both tasks correctly
1= Performs one task correctly
Platelet count <100,000
2=Performs neither task correctly
Bp > 185/110
0= Normal
Gaze
INR >1.7 or PT>15
1= Partial Gaze Palsy
Abnormal Blood Glucose (<50)
2= Forced Deviation
Advanced Age
0= No visual loss
Visual Fields
1= Partial Hemianopia
Intracerebral Hemorrhage
2= Complete Hemianopia
Rapid Improvement (document NIHSS)
3= Bilateral Hemianopia
Stroke Symptoms Too Mild
Facial Movement
0= Normal symmetrical movements
Other____________________
(Facial Paresis)
1= Minor paralysis
2= Partial paralysis
3= Complete paralysis of one or both
Indicated per Dr._________________
Motor Function-
0= No drift
R
R
Arms
1= Drift
(Right and Left)
2= Some effort against gravity
3= No effort against gravity
Notes:_______________________________
4= No movement
UN= Amputation or joint fusion
L
L
____________________________________
0= No drift
Motor Function-
R
R
____________________________________
Legs
1= Drift
____________________________________
(Right and Left)
2= Some effort against gravity
____________________________________
3= No effort against gravity
____________________________________
4= No movement
L
L
UN = Amputation or joint fusion
____________________________________
Limb Ataxia
0= Absent
____________________________________
1= Present in one limb
____________________________________
2= Present in two limbs
____________________________________
UN= Amputation or joint fusion, explain
____________________________________
Sensory
0= Normal: no sensory loss
1= Mild to moderate sensory loss
____________________________________
2= Severe to total sensory loss
____________________________________
0= No aphasia
Best Language
____________________________________
1= Mild to moderate aphasia
____________________________________
2=Severe Aphasia
____________________________________
3= Mute
____________________________________
Dysarthria
0= Normal
1= Mild to moderate dysarthria
2= Severe dysarthria
UN=Intubated or other physical barrier, explain
Nurse Signature
Date/Time
Extinction &
0= No abnormality
Inattention
1= Visual, tactile, auditory, spatial, or personal
/
(formerly Neglect)
inattention
MD/ARNP Signature
Date/Time
2= Profound hemi-inattention/extinction
/
Total Score
ACUTE STROKE RESPONSE TEAM FORM
PATIENT IDENTIFICATION
Via Christi Template
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