bjective assessment
Please seek medical help if any of the above apply or else confirm that you have checked that none do.
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| Has the person had an acute stroke within last 24 hours? Any of these present: face droop, slurred speech, severe headache, one sided numbness? | |
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| Can they sit unaided and lean in all directions (sideways/backwards/forwards) without problem? | |
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| With their eyes closed can they feel the impaired limb being moved passively by another person? | |
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| Can the patient move from sit to stand with assistance of 1 person? For a stroke patient, sitting to standing is best achieved slowly with two people to begin with, as blood pressure needs monitoring | |
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| Can the patient move from sit to stand with assistance of 2 people? For a stroke patient, sitting to standing is best achieved slowly with two people to begin with, as blood pressure needs monitoring | |
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1: Has the person had an acute stroke within last 24 hours? Any of these present: face droop, slurred speech, severe
headache, one sided numbness?
Yes = see a
doctor; No = go to 2
2: Has the patient been cleared by a medical team for assessment?
Yes = go to 3; No = see a
doctor
3: Can the patient move their right leg and arm without issues?
Yes = go to 6; No = go to 4
4: Is the right leg or arm stiff to move?
Yes = Right Hemiplegia increased tone; (to 5) No = go to 5
5: Is the right leg or arm heavy and floppy?
Yes = Right Hemiplegia low tone; (to 6) No = go to 6
6: Can the patient move their left leg and arm without issues?
Yes = go to 9 No = go to 7
7: Is their left leg or arm stiff to move?
Yes = Left Hemiplegia increased tone; (to 8) No = go to 8
8: Is their left leg or arm heavy and floppy?
Yes = Left hemiplegia low tone; (to 9) No = go to 9
9: Can they sit unaided and lean in all directions (sideways/backwards/forwards) without problem?
Yes = go to 10; No = Poor sitting balance (to 10)
10: With their eyes closed can they feel the impaired limb being moved passively by another person?
Yes = go to 11; No = Reduced proprioception (go 11)
11: With eyes closed, can they feel impaired limb being touched?
Yes = go to 12; No = reduced sensation (go 12)
12: Can the affected shoulder be moved fully by another person?
Yes = go to 13;
No = reduced range of movement (go 13)
13: Does the shoulder look out of place?
Yes = shoulder subluxation (go 14); No = go to 14
14: Is the shoulder painful?
Yes = shoulder pain (go 15); No = go to 15
15: Can the affected elbow be fully straightened?
Yes = go to 16; No = elbow contracture (go 16)
16: Can the affected wrist be moved through full range?
Yes = go to 17; No = wrist contractue (go 17)
17: Can the hand/fingers be fully opened?
Yes = go to 18; No = hand flexion contractue (go 18)
18: Can the affected hip be moved fully through range?
Yes = go to 19; No = hip contracture (go 19)
19: Can the knee be moved fully through range?
Yes = go to 20; No = knee contracture (go 20)
20: Can the ankle be moved fully through range?
Yes = go to 21; No = ankle contracture (go 21)
21: Can the patient roll to the left and right on a bed?
Yes = go to 22; No = poor rolling ability (go 22)
22: Can the patient lie on their back and lift their bottom?
Yes = go to 23; No = poor pelvic titlting (go 23)
23: Can the patient move from lying to sitting unaided?
Yes = go to 26;
No = go to 24
24: Can the patient move from lying to sitting with assistance from one person?
Yes = A.O.1 bed transfers (go 25); No = go to 25
25: Can the patient move from lying to sitting with assistance from two people?
Yes = A.O.2 bed transfers (go 26); No = A.O.1 sit to stand (go 26)
26: Can the patient move from sit to stand unaided?
Yes = go to 29; No = go to 27
27: Can the patient move from sit to stand with assistance of 1 person? For a stroke patient, sitting to standing is best
achieved slowly with two people to begin with, as blood pressure needs monitoring
Yes = go to 28;
No = A.O.1 sit to stand (go 28)
28: Can the patient move from sit to stand with assistance of 2 people? For a stroke patient, sitting to standing is best
achieved slowly with two people to begin with, as blood pressure needs monitoring
Yes = A.O.2 Sit to stand (go to 29); No = Hoist transfers (go to 29)
29: Can the patient stand and lean in all directions independently?
Yes = go to 30;
No = Poor standing balance (go 30)
30: Can the patient walk unaided?
Yes = go to 33; No = go to 31
31: Can the patient walk with a stick/zimmer frame unaided?
Yes = go to 33;
No = go to 32
32: Can the patient walk with assistance of one or two people?
Yes = supervised mobility (go to
33); No = Wheelchair mobility (go to 33)
33: Do they have an altered walking pattern (abnormal gait)?
Yes = go to 34;
No = END
34: Can they stand on affected leg and step with other leg?
Yes = END; No = Reduced proprioception/ ability to step
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