University:
Merced College
Course:
REGN - 34 | Advanced Medical/Surgical Nursing and Pediatric Nursing
Academic year:

2023
Views:

428

Pages:

2
Author:

carnificoy4ml

Stroke Scale CATEGORY 1a. Level of consciousness Alert, Drowsy, etc 1b. LOC Questions Month, age 1c. LOC Commands Open/close eyes, make a ﬁst & let go 2. Best Gaze Eyes open - pt follows examiner’s ﬁngers or face. 3. Visual Introduce visual stimulus/threat to pt’s visual ﬁeld quadrants. Cover 1 eye and hold up ﬁngers in all 4 quadrants. 4. Facial Palsy Show teeth, raise eyebrows and squeeze eyes tightly shut. 5.a Motor Arm - Left Elevate extremity to 90 degrees and score drift/movement. Count to 10 out loud and use ﬁngers for visual cue. 5.b Motor Arm - Right Elevate extremity to 90 degrees and score drift/movement. Count to 10 out loud and use ﬁngers for visual cue. STROKE SCALE SCORE 0 1 2 3 Alert Drowsy Stuporous Coma 0 1 Answers both Answers one correctly correctly 2 Incorrect 0 1 2 Obeys both correctly Obeys one correctly Incorrect 0 1 2 Normal Partial gaze palsy Forced deviation 1 2 0 No visual loss Partial Complete hemianopsia hemianopsia 3 Bilateral hemianopsia 0 1 2 3 Normal Minor Partial Complete 2 3 0 1 No Drift Drift No eﬀort Can’t resist against gravity gravity 4 No Movement NT = Amputation, joint fusion 0 1 No Drift Drift 2 3 Can’t resist No eﬀort against gravity gravity 4 No Movement NT = Amputation, joint fusion TOTAL = 6.a Motor Leg - Left Elevate extremity to 30 degrees and score drift/movement. Count to 5 out loud and use ﬁngers for visual cue. 6.b Motor Leg - Right Elevate extremity to 30 degrees and score drift/movement. Count to 5 out loud and use ﬁngers for visual cue. 7. Limb Ataxia Finger to nose, heal down shin 8. Sensory Pin prick to face, arms, trunk, and legs compare sharpness side to side 9. Best Language Name items, describe picture, and read sentences. Don’t forget glasses if they normally wear them. 10. Dysarthria Evaluate speech clarity by pt reading or repeating words on list. 0 1 2 3 4 No Drift Drift Can’t resist gravity No eﬀort against gravity No Movement NT = Amputation, joint fusion 0 1 2 3 4 No Drift Drift Can’t resist gravity No eﬀort against gravity No Movement NT = Amputation, joint fusion 0 1 2 Absent Present in one limb Present in two limbs 0 1 2 Normal Partial loss Severe Loss 0 1 2 3 No aphasia Mild to moderate aphasia Severe aphasia Mute 0 1 2 Normal articulation Mild to moderate dysarthria Near to unintelligible or worse NT = Intubated or other physical barrier 11. Extinction and Inattention Use information from prior testing or double simultaneous stimuli testing to identify neglect. Face, arms, legs, and visual ﬁelds. 0 1 No neglect Partial neglect 2 Complete neglect NT = Not Testable acceptable as noted above Score Stroke Severity 0 1-4 5-15 16-20 21-42 No stroke symptoms Minor stroke Moderate stroke Moderate to severe stroke Severe stroke TOTAL =

Tool for Stroke Patients and How to Identify

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