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Nama Pasien :................................................ Umur :................................................

TES DEFISIT 1.a. Derajad kesadaran

NIHSS

Diagnosis :..................................................................... MRS / KRS :.....................................................................


NIHSS Masuk NIHSS Keluar

RESPON Sadar[0] Mengantuk[1] Stupor[2] Koma [3] Menjwb. 2 pertanyaan tepat [0] Menjwb. 1 pertanyaan tepat [1] Salah [2] Mengikuti 2 perintah tepat [0] Mengikuti 1 perintah tepat[1] Salah [2] Normal [0] Abnormal pd satu mata [1] Abnormal pd kedua mata [2] Tak ada gangguan visual [0] Hemianopia parsial [1] Hemianopia komplit [2] Hemianopia bilateral [3] Normal [0] Minor [1] Parsial [2] Komplit [3] Tak ada kelumpuhan [0] Jatuh sebelum 10 detik [1] Tdk dpt diluruskan scr penuh [2] Tdk dpt menahan gravitasi [3] Tdk ada gerakan [4] Tak ada kelumpuhan [0] Jatuh sebelum 10 detik [1] Tdk dpt diluruskan scr penuh [2] Tdk dpt menahan gravitasi [3] Tdk ada gerakan [4] Tak ada kelumpuhan [0] Jatuh sebelum 10 detik [1] Tdk dpt diluruskan scr penuh [2] Tdk dpt menahan gravitasi [3] Tdk ada gerakan [4] Tak ada kelumpuhan [0] Jatuh sebelum 10 detik [1] Tdk dpt diluruskan scr penuh [2] Tdk dpt menahan gravitasi [3] Tdk ada gerakan [4] Tak ada [0] Pd ekstremitas atas atau bawah [1] Pada keduanya [2] Normal [0] Parsial [1] Terganggu berat [2] Tak ada afasia [0] Afasia ringan sedang [1] Afasia berat [2] Bisu [3] Normal [0] Disatria ringan sedang [1] Distartria berat [2] Normal[0] Ringan [1] Hebat [2]

1.b

Derajad kesadaran (menjawab pertanyaan)

1.c

Derajad kesadaran (melaksanakan perintah)

Gerakan mata konjugat horisontal [GAZE]

Lapang pandang pada tes konfrontasi

4.

Kelumpuhan wajah

5.

Motorik lengan kanan

5.

Motorik lengan kiri

6.

Motorik tungkai kanan

6.

Motorik tungkai kiri

7.

Ataksia ekstremitas

8.

Sensorik

9.

Afasia

10.

Disartria

11.

Neglect/inattention

TOTAL SKOR NIHSS

MODIFIED RANKIN SCALE (MRS) TOTAL (06) : ...................................................................(0)No symptoms at all (1) No significant disability despite symptoms; able to carry out all usual duties and activities (2)Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance (3)Moderate disability; requiring some help, but able to walk without assistance (4)Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance(5)Severe disability; bedridden, incontinent and requiring constant nursing care and attention(6)Dead