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SCRN > Stroke Scales > Flashcards

Stroke Scales Flashcards

1
Q

GCS

A 
Best score is 15
Coma scale
Best eye response 
Best verbal response
Best motor response
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2
Q

In GCS, a person with spontaneous eye opening would get a score of

A

4

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3
Q

In GCS, a person who opens eyes in response to verbal command, speech, or shout would score

A

3

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4
Q

In GCS a person who open eyes to pain would score

A

2

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5
Q

In GCS a person who has absent eye opening scores

A

0

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6
Q

Best verbal response in GCS, a person that is orientated would score

A

5

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7
Q

Best verbal response in GCS with confused conversation but able to answer questions would score

A

4

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8
Q

Best verbal response in GCS inappropriate responses but understandable responses would score

A

3

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9
Q

Best verbal response in GCS incomprehensible speech would score

A

2

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10
Q

Best verbal response in GCS with no speech would score

A

0

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11
Q

Best motor response in GCS and can obey commands for movement would score

A

6

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12
Q

Best motor response in GCS with purposeful movement to painful stimuli would score

A

5

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13
Q

Best motor response GCS for pain withdrawal

A

4

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14
Q

Best motor response GCS abnormal spastic flexion- decorticate posturing would score

A

3

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15
Q

Best motor response in GCS for extension posturing - decerebrate would score

A

2

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16
Q

Best motor response in GCS with no movement would score

A

1

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17
Q

FOUR coma scale includes what?

A

Respirations and brainstem

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18
Q

What’s the max NIHSS

A

42

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19
Q

NIHSS of <3 usually correlates with

A

A good outcome

20
Q

Pts can usually be dc Home with a NIHSS

A

<5

21
Q

Discharge dispo for pts with a NIHSS 7-13

A

Usually rehab

22
Q

Dispo for pts with NIHSS >14

A

SNF

23
Q

What is considered a significant neurologic change on the NIHSS

A

2-4 points

24
Q

What are the NIHSS categories?

A 
1a - LOC
1b - LOC questions
1c - LOC commands
2 - Best gaze
3 - Visual
4 - Facial palsy
5 - Motor arm
6 - Motor leg
7 - Limb ataxia
8 - Sensory
9 - Best language
10 - Dysarthria
11 - Extinction and inattention
25
Q

What is the ICH scale used for?

A

Intracerebral hemorrhages Predicts 30 day mortality and 12 month functional outcome

26
Q

Which scale is scored 1-6 and predicts 30 day mortality?

A

ICH scale

27
Q

What is assessed in a ICH scale

A 
GCS
ICH volume 
IVH
Location
Age
28
Q

What is the Hunt & Hess scale?

A 
For subarachnoid hemorrhage
Helps to make the decision of when to go to OR
Used Roman numerals
Score I - V
Score is based on clinical findings
29
Q

In the hunt and Hess scale, scores of I - III

A

Have a better outcome but need OR quickly

30
Q

In the hunt Hess scale scores of IV - V

A

Have a worse outcome and must be stabilized before going to the OR

31
Q

A hunt Hess score of I would exhibit

A

Asymptomatic or mild HA

32
Q

A hunt Hess score of II would exhibit signs of

A

Moderate to sever HA with oculomotor palsy

33
Q

A hunt Hess score of III would exhibit

A

Confusion, drowsiness, or mild focal signs

34
Q

A hunt Hess score of IV would exhibit

A

Stupor bit can localize to pain

35
Q

A hunt Hess score of V would exhibit

A

Coma- posturing or no motor response

36
Q

What is the Fisher-Miller scale used for?

A

Measures volume of SAH BLOOD ON CT
Predicts cerebral vasospasm
Scoring is 1-4

37
Q

What is the ABCD2 score

A
  • Score for TIA to predict the 90 day AIS risk

- Used to determine hospitalization need vs d/c and f/u

38
Q

On the ABCD a score of 1-3

A

1% 2 day risk

D/C

39
Q

On the ABCD risk a 4-5

A

4.1% 2 day risk
8-12% 90 day risk
Admit

40
Q

A ABCD a score of 6-7 is

A

8.1% 2 day risk
17-22% 90 day risk
Admit

41
Q

What’s the max score on a ABCD TIA risk score?

A

9

42
Q

What is the modified rankin used for?

A

Measures functional outcome

43
Q

What is the scale in modified rankin

A

0-6

44
Q

What is the Barthel Index

A 
Stroke outcome scale
Measures self care and mobility 
Correlates with infarcts volume 
Normal = 100
The lower the score the higher the disability
45
Q

What is measured in the Barthel Index

A 
Bowel
Bladder
Grooming
Toileting
Feeding
Transferring
Mobility 
Dressing
Stairs
Bathing
46
Q

What is the FIM

A 
Functional outcome scale
Measures 18 ADLS
Used in rehab
Scored 1-7
1= total assist
7= independent

SCRN (26 decks)

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