M4L2: Check-in Activity

Name of student: Justine Ysabelle C. Bernardo Name of instructor: Dr. Rochelle V. Benlota
Course and section: BSN3A Date of submission: March 4, 2023
The National Institutes of Health Stroke Scale, or NIH Stroke Scale (NIHSS) is a tool used by healthcare
providers to objectively quantify the impairment caused by a stroke. The NIHSS is composed of 11 items,
each of which scores a specific ability between a 0 and 4. For each item, a score of 0 typically indicates
normal function in that specific ability, while a higher score is indicative of some level of impairment.
Instruction: Make a list of the 11 items included in the NIHSS and write the corresponding scores for each
item. You may also include the minimum to maximum possible total scores with their interpretation based
on stroke severity.

CATEGORY SCALE DESCRIPTION

1a. Level of Consciousness (LOC) 0 = Alert
1 = Arousable by minor stimulation
2 = Obtunded, strong stimulation to attend
3 = Unresponsive, or reflexive responses only
1b. LOC questions (month, age) 0 = Answers both correctly
1 = Answers one correctly
2 = Both incorrect
1c. LOC commands (open, close eyes; make fist, 0 = Obeys both correctly
let go) 1 = Obeys one correctly
2 = Both incorrect
2. Best gaze (eyes open – patient follows 0 = Normal
examiner’s finger of face) 1 = Partial gaze palsy
2 = Forced deviation
3. Visual (introduce visual stimulus/threat to 0 = No visual loss
patient’s visual field quadrants) 1 = Partial hemianopsia
2 = Complete hemianopsia
3 = Bilateral hemianopsia
4. Facial palsy (show teeth, raise eyebrows, and 0 = Normal
squeeze eyes shut) 1 = Minor
2 = Partial
3 = Complete
5a. Motor; arm – left (elevate extremity to 90 0 = No drift
degrees and score drift/movement) 1 = Drift but maintains in air
2 = Unable to maintain in air
3 = No effort against gravity
4 = No movement
N/A = Amputation, joint fusion (explain)
5b. Motor; arm – right (elevate extremity to 90 0 = No drift
degrees and score drift/movement) 1 = Drift but maintains in air
2 = Unable to maintain in air
3 = No effort against gravity
4 = No movement
N/A = Amputation, joint fusion (explain)
6a. Motor; leg – left (elevate extremity to 30 0 = No drift
degrees and score drift/movement) 1 = Drift but maintains in air
 2 = Unable to maintain in air
3 = No effort against gravity
4 = No movement
N/A = Amputation, joint fusion (explain)
6b. Motor; leg – right (elevate extremity to 30 0 = No drift
degrees and score drift/movement) 1 = Drift but maintains in air
2 = Unable to maintain in air
3 = No effort against gravity
4 = No movement
N/A = Amputation, joint fusion (explain)
7. Limb ataxia (finger-to-nose and heel-to-shin 0 = Absent
testing) 1 = Present in one limb
2 = Present in two limbs
8. Sensory (pinprick to face, arm, trunk, and leg – 0 = Normal
compare side to side) 1 = Mild to moderate loss
2 = Severe to total loss
9. Best language (name items, describe a picture, 0 = No aphasia
and read sentences) 1 = Mild to moderate aphasia
2 = Severe aphasia
3 = Mute
10. Dysarthria (evaluate speech clarity by having 0 = Normal
patient repeat words) 1 = Mild to moderate dysarthria
2 = Severe dysarthria, mostly unintelligible or
worse
N/A = Intubated or other physical barrier
11. Extinction and inattention (use information 0 = No abnormality
from prior testing to score) 1 = Visual, tactile, auditory, or other extinction to
bilateral simultaneous stimulation
2 = Profound hemiattention or extinction to more
than one modality
TOTAL SCORE

Reference:
Hinkle, J., & Cheever, K. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th ed.,

Vol. 2, p. 2016). Philadelphia Wolters Kluwer Health, Lippincott Williams & Wilkins.