Organization Name
Procedure for Use of the Canadian
Neurological Scale Observation Record
Document Number:
Initial Issue Date:
Last Revision Date:
Approved By:
Applies To:
Purpose
To describe the procedure for the assessment of acute stroke patients using the Canadian
Neurological Scale.
Definitions
Canadian Neurological Scale (CNS): The Canadian Neurological Scale was designed to assess
neurological function in conscious stroke patients. It includes an assessment of level of
consciousness, orientation, aphasia, and motor strength. Each domain is assigned a score, and a
total score from 1.5 to 11.5 is calculated.
Alert: Patient is awake and alert and has a normal level of consciousness.
Drowsy: Patient rouses when stimulated verbally and remains awake and alert for short periods
but tends to doze.
Stuporous: Patient responds to loud verbal stimuli and/or strong touch; may vocalize but does
not completely wake up.
Comatose: Patient responds to deep pain with purposeful movement, non-purposeful movement
or no response.
Expressive Speech Deficit: Patient can understand verbal speech, but is unable to say the word,
or cannot think of the right word.
Receptive Speech Deficit: Patient is unable to understand both spoken and written words.
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Equipment
Keys, Watch, Pencil/Pen, Blood Pressure Machine and Thermometer
General Guidelines
The Heart and Stroke Foundation's Best Practice Guidelines for Stroke Care outlines the
frequency for assessing neurological status using the Canadian Neurological Scale based on
different clinical situations or phase of care in the sample care guides. These care guides are
based on best evidence and can serve as a reference for staff. However, it is essential that
clincians follow the physician orders or clinical pathway guidelines for frequency for assessing
neurological status using the Canadian Neurological Scale within their organization.
The patient’s identification must be stamped on the top corner of each side of the Canadian
Neurological Scale Observation Record.
Write all information in blue/black ink unless otherwise directed.
Initials, signature and designation must appear in the signature section.
Significant findings are indicated by an asterisk * and documentation made in the patient’s chart.
Specific Guidelines
CARDIOVASCULAR
Graph all vital signs, temperature, blood pressure, pulse and respirations as ordered. Indicate time
of the assessment in the box provided.
When recording blood pressure, identify whether the measurement was obtained by cuff, noninvasive blood pressure cuff, arterial line or Doppler.
As appropriate, identify right versus left arm and sitting versus lying.
Re-label only when the measurement has been obtained by an alternate method of limb.
Document respiratory rate, percentage of oxygen in use and oximetry as per order and
organization policy.
Organizations or clinicians can use the additional lines to add additional monitoring of acute
stroke patients e.g. angioedema or bleeding for the patient who has received tPA.
PUPILS
Record size of the pupils in mm using the pupil scale prior to the application of the light
stimulus. Indicate the reaction of pupils as either: + = Brisk Reaction, S = Sluggish Reaction or = No Reaction. If the eyes are closed due to swelling record "C".
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Procedure
Note: The CNS Scale is to be used for alert or drowsy patients. If patient is comatose or
stuporous, use the Glasgow Coma Scale.
SECTION A: MENTATION
Mentation involves assessing Level of Consciousness, Orientation, and Speech.
ASSESS LEVEL OF CONSCIOUSNESS
Score "3" for Alert if the patient is alert, alert and has a normal level of consciousness.
Score "1.5" for Drowsy if the patient rouses when stimulated verbally and remains awake and
alert for short periods but tends to doze.
If the patient is stuporous or comatose use the Glasgow Coma Scale for assessing
neurological function.
ASSESS ORIENTATION
Score "1.0" for Oriented if the patient is able to tell the examiner the place, i.e., city or hospital
and time, i.e., correct month and year. If early in month (i.e., first three days) previous month is
acceptable. Speech may be mispronounced or slurred but intelligible. If the patient is able to
write the place and time, this is also an acceptable response.
Score "0.0" for Disoriented or Non Applicable if for any reason the patient cannot answer the
questions about place and time (i.e., does not know the answer, gives the wrong answer, answers
only partially, cannot express self because of unintelligible speech or ignores the question).
If the patient’s first language is not English and an interpreter is used to complete the assessment,
initially complete the assessment without the interpreter as a baseline and then with the
interpreter. If an interpreter is used, indicate that on the documentation tool.
ASSESS SPEECH
Assess Receptive Language
Ask patient to "Close your eyes", "Point to the ceiling" and "Does a stone sink in water?" Repeat
question twice if necessary. Do not mimic commands.
NOTE: For the purpose of this procedure the original protocol as described in the research
articles is followed. Some organizations may not ask the question “Does a stone sink in
water?” Follow the Receptive Language testing used within your organization.
If the patient obeys the 3 commands, continue to assess expressive language.
If the patient obeys 2 or less commands, score "0" for receptive deficit, do not assess expressive
language and move to assess Motor Function – Section A2: Receptive Deficit.
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Assess Expressive Language
Objects needed: pencil/pen, key, watch.
Show patient each item and ask patient to name: pencil, key and watch. Allow patient time to
respond.
Again show the patient each item and ask the patient to state the use of the pencil, key and watch.
One word telegraphic answers are acceptable.
NOTE: If the patient writes the answer to any of the above questions, this is NOT
acceptable as expressive speech is being assessed.
Grading: Patient is scored according to the worst speech deficit.
If patient is unable to name all the 3 objects and their use, score the patient as having an
Expressive Deficit and scored "0.5".
If the patient names all three objects and the use of the 3 objects, score "1.0" for Normal Speech.
If the patient’s speech is slurred, indicate “SL” beside the appropriate speech grading for
the patient.
If the patient is scored as having normal speech or expressive speech deficit, assess Motor
Function using Section A1: No Receptive Deficit.
MOTOR FUNCTION: SECTION A1 OR A2
If patient is able to follow directions and cooperate, complete section Motor Function A1 - No
Receptive Deficit.
If patient is scored as a receptive deficit, complete section Motor function A2 - Receptive Deficit.
Complete one section only on each patient, i.e. A1 or A2 not both.
When evaluating strength and range of motion in limbs always test both sides of the body, record
the worst deficit identified and the side of the body the deficit is in.
If weakness is present, identify which side has the weakness with "R" or "L" in the slot with the
grade, e.g.: R - 0.5.
The Canadian Neurological Scale is meant to identify changes in motor function in the acute
stroke patient. If on admission it is identified that the patient has a pre-existing permanent
deficits related to a previous stroke or other medical condition, e.g. right sided significant deficit
or right sided amputation etc, that is not on the side of the new stroke motor deficit indicate this
on the Canadian Neurological Scale form and score the deficit related to the new motor deficit.
NOTE: For the purpose of this procedure, the original motor grading terms as described in
the research articles were used. Some regions may use different terms to describe each
level, e.g. Moderate or Severe may be used instead of Significant, and Complete may be
used instead of Total. Follow the motor grading scale used within your organization.
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Motor Function Section A 1 (No Receptive Deficit)
Complete only if patient is able to obey commands and follow directions and was assessed in
Speech section to have an expressive speech deficit or normal speech.
Complete one section only on each patient, i.e. A1 or A2 not both.
Face
Observe the patient’s face; ask them to smile or show their teeth or gums and note symmetry of
mouth and nasal labial folds.
Grading: Assess both sides but score the side of the face with the worst deficit and identify the
side with the weakness by using either "R" or "L" in the grading slot.
No weakness, score "0.5": Symmetrical grin, no asymmetry in smile.
Weakness Present "0.0": Facial asymmetrical, i.e., one corner of mouth lower than other, either
at rest or while showing teeth.
Upper Limb (Proximal)
Patient should be tested in sitting position if possible. Have patient abduct their arms 90 degrees
to the side (flap like a bird).
If patient is lying in bed, have patient elevate arms in front of patient. Apply resistance midway
between the shoulders and elbows.
Grading: Assess both arms but score the arm with the worst motor deficit and identify the side
with the weakness with either "R" or "L" in grading slot.
None, score"1.5": No weakness of the proximal arm.
Mild, score "1.0": Mild weakness of the proximal arm. Normal range of motion against gravity
but succumbs to resistance by observer either partially or totally. Movement to 90 degrees but
unable to oppose pressure.
Significant, score "0.5": The patient cannot overcome gravity in range of motion, i.e.,
movement or arms in abduction less than 90 degrees.
Total, score "0.0": No movement of the proximal arm.
Upper Limb (Distal)
Patient is tested sitting or lying position. Have patient raise arms in front of him with wrists
cocked back (dorsiflexed hands). Apply resistance to wrists while stabilizing the patient’s arm.
Grading: Assess both arms but score the arm with the worst motor deficit and identify the side
with the weakness with either "R" or "L" in grading slot.
None, score "1.5": No weakness in wrist.
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Mild, score "1.0": Mild weakness, normal range of motion, i.e., can "cock-back" wrist but
unable to oppose pressure of examiner.
Significant, score "0.5": Some movement of fingers but cannot completely overcome gravity in
full range of motion, i.e., cannot cock-back wrists.
Total, score "0.0": Absence of movement of wrists.
Proximal Legs
Patient is tested lying in bed. Have patient flex thighs toward trunk with knees flexed at 90
degrees. Push down on each thigh one at a time.
Grading: Assess both legs but score the leg with the worst motor deficit and identify the side
with the weakness with either "R" or "L" in grading slot.
None, score "1.5": No weakness of the proximal leg.
Mild, score "1.0: Mild weakness, can lift leg to 90 degrees, but unable to oppose pressure either
partially or total.
Significant, score "0.5": Severe weakness of the proximal leg, the patient cannot flex hip to 90
degrees, partial movement against gravity.
Total, score "0.0": No movement of the proximal leg or only contraction of muscle without
actual movement of limb.
Distal Legs
Patient is tested lying in bed. Ask the patient to point toes and foot upward. Apply resistance
alternately to each foot after full movement has been completed.
Grading: Assess both legs but score the leg with the worst motor deficit and identify the side
with the weakness with either "R" or "L" in grading slot.
None, score "1.5": No weakness of the distal leg.
Mild, score "1.0": Mild weakness of the distal leg, can point foot and toes upward but unable to
oppose pressure.
Significant, score "0.5": Severe weakness of the distal leg, some movement of toes but cannot
lift toes or foot.
Total, score "0.0": No movement of the distal leg.
Motor Function Section A 2 (Receptive Deficit Present)
Complete this section only if patient cannot follow instructions and has been assessed as having a
receptive deficit in the Speech section.
Complete one section only on each patient, i.e. A1 or A2 not both.
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When evaluating strength and range of motion in limbs always submit both limbs to same testing
and record the side with the worst deficit.
If weakness is present, identify which side has the weakness with "R" or "L" in the slot with the
grade, e.g.: R - 0.5.
Face
Have patient try to mimic your grin and note symmetry of mouth and nasal labial folds. If patient
is unable to follow commands, observe facial response when pressure is applied to sternum.
Grading: Assess both side of the face but score the worst deficit and identify the side with the
weakness with either "R" or "L" in grading slot.
Symmetrical, score "0.5": Symmetrical grin, no asymmetry in smile.
Asymmetrical, score "0.0": Facial asymmetrical, facial weakness on one side, facial droop.
Arms
Elevate the patient’s arms outstretched at 90 degrees in front of patient. Observe if patient can
maintain it for 3-5 seconds, note asymmetry. If unable to elevate arms, test by applying nail bed
pressure bilaterally and compare response.
Grading: Assess both arms but score the arm with the worst deficit and identify the side with the
weakness with either "R" or "L" in grading slot.
Equal, score "1.5": Equal motor response in both arms.
Unequal, score"0.0": Unequal motor response.
Legs
Elevate one leg at a time to 90 degrees Observe if maintained for 3-5 seconds, note asymmetry. If
patient unable to cooperate, test by applying pressure to toenail beds bilaterally and compare
response.
Grading: Assess both legs but score the leg with the worst motor deficit and identify the side
with the weakness with either "R" or "L" in grading slot.
Equal, score "1.5": Able to maintain position or withdraw equally.
Unequal, score"0.0": Cannot maintain position or unequal withdrawing.
Documentation
Document the scores on the Canadian Neurological Scale form. Each domain is assigned a score,
and the total score is calculated. Minimum score is 1.5 and the maximum score is 11.5.
Add scores in Section A: Mentation and Motor Function Section A1 or Motor Function Section
A2 to obtain the total Canadian Neurological Scale Score.
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A decrease of more than 1 point from previous Canadian Neurological Scale may indicate
deterioration in the patient’s condition and requires notification of the physician.
If the patient experiences change in pupil size and reaction to light or vital signs this may indicate
deterioration in the patient’s condition and require notification of the physician.
References
Cote R, Hachinski V, Shurvell B, Norris J, & Wolfson C. The Canadian Neurological Scale: A
Preliminary Study in Acute Stroke. Stroke 1986;17:731-737.
Cote R, Battista R, Wolfson C, Boucher J, Adam J, & Hachinski V. The Canadian Neurological
Scale: Validation and Reliability Assessment. Neurology 1989;39:638-643.
Heart and Stroke Foundation of Ontario. Best Practice Guidelines for Stroke Care. Author:2003.
The Institute for Clinical Evaluative Sciences and the Canadian Stroke Network. Operations
Manual, The Registry of the Canadian Stroke Network. Author:2002.
The Toronto Hospital. Canadian Neurological Scale.
Developed By
CNS Working Group, Neurosciences Program, Hamilton Health Sciences, Hamilton, Ontario.
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