Introduction:

In the pre-hospital, nurses experience health/illness transitions in victims who present signs and symptoms of Stroke, using several instruments to perform their assessment. Subsequently, they activate the Via Verde promoting health gains for the victims.

Objective:

To map the instruments used to assess signs and symptoms in adult stroke victims in the pre-hospital setting.

Methods:

A scoping review was conducted following the method proposed by the Joanna Briggs Institute, with the following research question: Which instruments for assessing signs and symptoms in stroke victims are used by nurses in the pre-hospital setting? The selection of studies, extraction, and synthesis of data was performed by two independent reviewers.

Results:

The following assessment instruments are highlighted: Face Arm Speech Test (FAST), Los Angeles Prehospital Stroke Screen (LAPSS), Melbourne Ambulance Stroke Screen (MASS), Rapid Arterial Occlusion Evaluation (RACE), Los Angels Motor Score (LAMS), Cincinnati Prehospital Stroke Severity Score (CPSSS), Field Assessment Stroke Triage for Emergency Destination (FAST- ED), National Institute of Health Stroke Scale (NIHSS) and Postural Assessment Scale for Stroke Patients (PASS).

Conclusion:

All scales have advantages and disadvantages, translating into their specificity and sensitivity. However, primary studies in the area should be conducted to compare the existing scales, define the “most” recommended one, and explore the application of the assessment tools in different pre-hospital settings.

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