NIH Stroke Scale for nurses: the 15 scored items, a worked total, and its blind spots

Fifteen scored items across eleven categories

NINDS describes the scale as a checklist that scores alertness, communication and simple movements. Arms and legs are scored one limb at a time, which is how 11 categories become 15 numbers. The ranges below come from the NINDS form; item wording is summarized, not copied.

Adding the top of each range gives the maximum of 42. A limb that cannot be tested because of amputation or a fused joint is marked UN with a written reason rather than given a number.

Scoring rules that change the number

The form's instructions are strict, and exam items test them. Give the items in the listed order, record each score right away, and do not go back to change it. Score what the patient does, not what you think they could do. Do not coach, and score only the first answer on the orientation questions, with no partial credit for being close.

Some items score automatically or have special rules. A patient who is totally unresponsive on item 1a scores 2 on sensory and 3 on language. Ataxia is scored only when it is out of proportion to weakness, so a paralyzed limb scores 0 for ataxia. An intubated patient who cannot speak scores 1 on the orientation questions, while an aphasic patient who cannot understand them scores 2.

Hypothetical practice case: scoring one patient

Hypothetical scenario for practice, not a real exam item: a patient is alert and gets the month right but the age wrong. Gaze is partly limited, there is a partial loss of one visual field, and the lower face is nearly paralyzed. The right arm drifts to the bed with some effort against gravity, the right leg drifts but does not hit the bed, the patient feels pinprick as dull on the right, has some word-finding trouble and slurs some words. The left side is normal.

The common error is scoring the right arm 1 because it started to drift. Drift that stays off the bed is 1; reaching the bed with some effort against gravity is 2. The other common error is coaching the patient to retry, which the instructions forbid.

What the total tells the team

Higher totals mean a more severe stroke. MDCalc notes that the score correlates with infarct size on imaging, that patients scoring 4 or less generally do well, and that many protocols flag scores above 22 for higher bleeding risk with clot-dissolving treatment. MDCalc also states the scale is not a guide to choosing who receives that treatment. Severity labels such as minor or moderate vary between sources, so use your facility's.

For the nurse, the trend matters most. The NINDS form lists set times to repeat the scale: baseline, 2 hours after treatment, 24 hours after onset, 7 to 10 days and 3 months, and stroke units add checks under their own protocols. A rising score between checks means the patient is worse and is reported right away, along with a full neuro check.

Strokes and deficits the NIHSS undercounts

MDCalc warns that a patient with even a large posterior circulation stroke may still have a low or normal score, so dizziness, vomiting or trouble walking with a low total still needs escalation. MDCalc also lists facial movement, ataxia, neglect, level of consciousness and dysarthria as items with lower agreement between raters, and summarizes a 2023 study finding clinically meaningful nurse and neurologist score differences in about one in three initial scores.

The scale has no swallowing item. A low score does not clear a patient to eat or drink, so the bedside swallow screen is done separately before anything is given by mouth. Gait is not scored either, which is why a patient with a single-digit score can still be at high risk for falls.

Sources and further reading

NINDS: NIH Stroke Scale. Purpose of the scale, scoring 11 categories of alertness, communication and movement, link to the American Heart Association stroke scale course for training.

NINDS: NIH Stroke Scale form (PDF, Rev 10/1/2003). Item list and score ranges, administration rules (order, no going back, score what the patient does, no coaching, first answer only), automatic scores in coma, ataxia rule, UN for amputation, repeat intervals, no swallowing or gait item.

MDCalc: NIH Stroke Scale/Score (NIHSS). Correlation with infarct size, scores of 4 or less linked with favorable outcomes, protocols flagging scores above 22, not a guide to treatment selection, items with lower interrater reliability, nurse and neurologist score differences, low scores in posterior circulation stroke.