Scales Flashcards
Pulse Strength
0 = No pulse
1+ = Weak pulse, difficult to palpate
2+ = Weak but greater than 1
3+ = Normal
4+ = Too strong, bounding, aneurism, pathology
Hoehn & Yahr Parkinsons
Stage 1 Mild Sx, one side of body, not interfering with ADLs
Stage 2 Rigidity, other Sx BL, may have issues with walking but still independent
Stage 3
Loss of balance and increase in FALLS, ADLs become difficult but still independent
Stage 4
Severely disable, symptoms stronger. Still may walk with AD, requires help with ADLs
Loss of INDEPENDENCE
Stage 5
Always require care, bedridden or always in wheelchair
DEXA Scan
-1 to 0 is normal
-1 to -2.5 is osteopenia
-2.5 or lower is osteoporososis
ABI
> 1 potentially calcification due to PAD (1.4, 1.5, 2)
1 is normal
0.8-0.9 is mild arterial disease. early PAD (Treat issues)
Refer out…
0.4-0.8 is moderate PAD (may have intermittent claudication with
exercise)
Less than 0.4 is severe arterial disease, may have claudication at rest
Rancho Los Amigos Levels of Cognitive Functioning
Used to rate recovery of brain injury
I. No response - Completely unresponsive
II. Generalized response - Inconsistent and non-purposeful responses (body movement, vocalization, etc.)
III. Localized Response - Specific responses but inconsistent, simple commands sometimes
PROM for I-III then AROM moving forward
Gait training moving forward
IV. Confused Agitated - Confused, agitated behaviors, low memory recall, inability to concentrate. Brief gross attention
V. Confused Inappropriate - The patient can now respond to simple commands but has difficulty with complex demands. Easily distracted. Says inappropriate things, cannot learn new info. Increased gross attention and ability to socialize on automatic level
VI. Confused Appropriate - Responses are relevant. Carryover for tasks like self-care. Past memories coming. Consistent with simple commands. Goal-directed behavior
VII. Automatic - Appropriate, now oriented, but robot-like
VIII. Purposeful Apropiate - Back decent just lacking from before, can learn
IX. Stand by assist
X. Modified Independent
Wagner Ulcer Grade Classification
0 - No open lesion but may have one, healed ulcer, bony deformity
1- Superficial, no subcutaneous
2 - Deep ulcer into subcutaneous, and could be exposing muscle bone, ligament, tendon
3 - Deep ulcer with osteitis, abscess osteomyelitis (infected)
4 - Gangrene of digit
5 - Gangrete of foot (must be amputated)
TNM System for Cancer Staging
Stage 0 (carcinoma stage only in early cells, only some cancers)
Stage 1 - Limited to tissue of organ, NO lymph nodes involved
Stage 2 - Spread to nearby tissues, some signs in lymph node
Stage 3 - Adjacent tissue spreading and deeper structures, metastasizing of lymph nodes
Stage 4 - To other organs and regions with metastasizing
Modified Ashworth Scale
0 - No tone present
1 - Slight catch at the end
1+ - Slight catch and resistance after catch throughout less than half of movement
2 - Increased tone throughout motion, but easy to move
3 - Increased tone, difficult to move
4 - Rigid cant move (serial casting probably required?)
Glasgow Coma Scale
Eye response
Score is 1-4
Verbal response
Score 1-5
Motor response
Score 1-6
Remember 3 is lowest because no response is 1
15 is highest
12-15 = mild
9-12 = moderate
8 and below = severe
Gold COPD
Stage 1: Fev1 >=80 percent of normal value
Stage 2: FEV 1 50-79 of normal
Stage 3: 30-49
Stage 4: Less than 30
Cancer
BP scale
el
Wells score DVT
less than 1 is low risk
1-2 is mod risk
2 and up is high risk
*alternative diagnosis is -2
*other are obvious signs + cancer
PE is same but 0-6
Apgar score
Determines the health of newborns and if they need immediate medical attention
taken 1 min and 5 min after
7-10: good condition
<5 neuromotor dysfunction
<3 requires immediate medical attention
Remember deep tendon reflex
0 is no response
2+ is normal middle point
4+is very brisk, hyperreflex
Superficial: present or absent
