SCRN Study Guide #1 | Questions with 100%
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Terms in this set (193)
BARTHEL INDEX Barthel Index
• This evaluation is a measure of functional ability
to manage ADL's and degree of help needed.
- Feeding
- Bathing
- Grooming
- Dressing
-Bowel -Bladder -Toileting -Transfers -Stairs
- Mobility • Mahoney FI, Barthel D. "Functional
evaluation: the Barthel Index.Maryland
,RANKIN SCORE Originally used as an interview (Rankin)
• Modified for clinical use (mRankin)
• Commonly used as an outcome point in research
due to ease of application
• 0 - No symptoms. • 1 - No significant disability.
Able to carry out all usual activities, despite
some symptoms. • 2 - Slight disability. Able to look
after own affairs without assistance, but
unable to carry out all previous activities.
• 3 - Moderate disability. Requires some help, but
able to walk unassisted.
• 4 - Moderately severe disability. Unable to
attend to own bodily needs without assistance,
and unable to walk unassisted.
• 5 - Severe disability. Requires constant nursing
care and attention, bedridden, incontinent.
• 6-Dead
FIM FUNCTIONAL The motor subscale includes: • Eating • Grooming
INDEPENDANCE MEASURE • Bathing
• Dressing, upper body • Dressing, lower body •
Toileting • Bladder management • Bowel
management
• Transfers - bed/chair/wheelchair • Transfers -
toilet • Transfers - bath/shower • Walk/wheelchair
• Stairs
The cognition subscale includes:
• Comprehension
• Expression Unique
Presentation by Pamela Nye (C) 2015
• Social interaction • Problem solving • Memory
,SOCRING FIM Each item is scored on a 7 point ordinal scale,
ranging from a score of 1 to a score of 7. The
higher the score, the more independent the
patient is in performing the task associated with
that item.
• 1 - Total assistance with helper • 2-
Maximalassistancewithhelper • 3 - Moderate
assistance with helper • 4 - Minimal assistance
with helper • • •
5 - Supervision or setup with helper 6 - Modified
independence with no helper 7 - Complete
independence with no helper
GCS SCALE BEST EYE RESPONSE
4 SPONTANEOUS TO BLINKING
3 OPENS TO VERBAL COMMNAD SHOUTING
2 OPENS TO PAIN
1 NONE
BEST VERBAL
1ORIENTED
2CONFUSED
3INAPPROTIRATE SLURRED
4INCOMPREHENSAB;E
5NONE
BEST MOTOR
1 OBEYS COMMANDS
2 PURPOUSEFUL MOTOR MOVEMENTS
3WITHDRAWS FROM STIMULI
4ABNORMAL FLEXION , POSTURING
6RIGID DECERABATE POSTURE
6NONE
, NIH SCORE Level of Conscious •
Orientation (age/month) •
Vision •
Best Motor (4 limbs) •
Sensory •
Best Language
Follows Commands
Best Gaze
Facial Palsy
Limb Ataxia
Neglect/Extinction
Dysarthria
WORST 42
BEST 0
LAPAS Los Angeles Pre Hospital Stroke Screen • Has
elements of the Cincinnati PreHospital
Stroke Scale + Blood glucose. • Takes 3-4 minutes
to perform. • Useful for paramedics
• Study result: 91% sensitivity and 97% specificity
for identification of stroke in the field. (K
Hunt & Hess Classification of Mild Headache, Alert and Oriented, Minimal (if
Subarachnoid Hemorrhage any) Nuchal Rigidity (H&H =1)
• Full Nuchal Rigidity, Moderate-Severe
Headache, Alert and Oriented, No Neuro Deficit
(Besides CN Palsy) (H&H=2)
• Lethargy or Confusion, Mild Focal Neurological
Deficits+3 (H&H=3)
• Stuporous, More Severe Focal Deficit (H&H=4)
• Comatose, showing signs of severe neurological
impairment (ex: posturing) (H&H=5) (MDCalc
website, 2014)
Presentation by Pamela Nye (C) 2015
Correct Answers | Verified | Latest Update 2026
Save
Terms in this set (193)
BARTHEL INDEX Barthel Index
• This evaluation is a measure of functional ability
to manage ADL's and degree of help needed.
- Feeding
- Bathing
- Grooming
- Dressing
-Bowel -Bladder -Toileting -Transfers -Stairs
- Mobility • Mahoney FI, Barthel D. "Functional
evaluation: the Barthel Index.Maryland
,RANKIN SCORE Originally used as an interview (Rankin)
• Modified for clinical use (mRankin)
• Commonly used as an outcome point in research
due to ease of application
• 0 - No symptoms. • 1 - No significant disability.
Able to carry out all usual activities, despite
some symptoms. • 2 - Slight disability. Able to look
after own affairs without assistance, but
unable to carry out all previous activities.
• 3 - Moderate disability. Requires some help, but
able to walk unassisted.
• 4 - Moderately severe disability. Unable to
attend to own bodily needs without assistance,
and unable to walk unassisted.
• 5 - Severe disability. Requires constant nursing
care and attention, bedridden, incontinent.
• 6-Dead
FIM FUNCTIONAL The motor subscale includes: • Eating • Grooming
INDEPENDANCE MEASURE • Bathing
• Dressing, upper body • Dressing, lower body •
Toileting • Bladder management • Bowel
management
• Transfers - bed/chair/wheelchair • Transfers -
toilet • Transfers - bath/shower • Walk/wheelchair
• Stairs
The cognition subscale includes:
• Comprehension
• Expression Unique
Presentation by Pamela Nye (C) 2015
• Social interaction • Problem solving • Memory
,SOCRING FIM Each item is scored on a 7 point ordinal scale,
ranging from a score of 1 to a score of 7. The
higher the score, the more independent the
patient is in performing the task associated with
that item.
• 1 - Total assistance with helper • 2-
Maximalassistancewithhelper • 3 - Moderate
assistance with helper • 4 - Minimal assistance
with helper • • •
5 - Supervision or setup with helper 6 - Modified
independence with no helper 7 - Complete
independence with no helper
GCS SCALE BEST EYE RESPONSE
4 SPONTANEOUS TO BLINKING
3 OPENS TO VERBAL COMMNAD SHOUTING
2 OPENS TO PAIN
1 NONE
BEST VERBAL
1ORIENTED
2CONFUSED
3INAPPROTIRATE SLURRED
4INCOMPREHENSAB;E
5NONE
BEST MOTOR
1 OBEYS COMMANDS
2 PURPOUSEFUL MOTOR MOVEMENTS
3WITHDRAWS FROM STIMULI
4ABNORMAL FLEXION , POSTURING
6RIGID DECERABATE POSTURE
6NONE
, NIH SCORE Level of Conscious •
Orientation (age/month) •
Vision •
Best Motor (4 limbs) •
Sensory •
Best Language
Follows Commands
Best Gaze
Facial Palsy
Limb Ataxia
Neglect/Extinction
Dysarthria
WORST 42
BEST 0
LAPAS Los Angeles Pre Hospital Stroke Screen • Has
elements of the Cincinnati PreHospital
Stroke Scale + Blood glucose. • Takes 3-4 minutes
to perform. • Useful for paramedics
• Study result: 91% sensitivity and 97% specificity
for identification of stroke in the field. (K
Hunt & Hess Classification of Mild Headache, Alert and Oriented, Minimal (if
Subarachnoid Hemorrhage any) Nuchal Rigidity (H&H =1)
• Full Nuchal Rigidity, Moderate-Severe
Headache, Alert and Oriented, No Neuro Deficit
(Besides CN Palsy) (H&H=2)
• Lethargy or Confusion, Mild Focal Neurological
Deficits+3 (H&H=3)
• Stuporous, More Severe Focal Deficit (H&H=4)
• Comatose, showing signs of severe neurological
impairment (ex: posturing) (H&H=5) (MDCalc
website, 2014)
Presentation by Pamela Nye (C) 2015
