常用脑卒中量表

常用脑卒中量表

1、改良Rankin量表（Modified Rankin Scale）

Modified Rankin Scale

(Internet Stroke Center at Washington University提供的Modified Rankin Scale)

SCORE DESCRIPTION

0 No symptoms at all

1 No significant disability despite symptoms; able to carry out all usual duties and activities

2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance

3 Moderate disability; requiring some help, but able to walk without assistance

4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance

5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention

6 Dead

Scores:0-6

2、日常生活能力量表－巴氏指数（Barthel Index）

THE Patient Name: ___________________________

BARTHEL Rater Name: ___________________________ INDEX Date: ___________________________

Activity Score

FEEDING

0 = unable

5 = needs help cutting, spreading butter, etc., or requires modified diet

10 = independent ______

BATHING

0 = dependent

5 = independent (or in shower) ______

GROOMING

0 = needs to help with personal care

5 = independent face/hair/teeth/shaving (implements provided) ______ DRESSING

0 = dependent

5 = needs help but can do about half unaided

10 = independent (including buttons, zips, laces, etc.) ______

BOWELS

0 = incontinent (or needs to be given enemas)

5 = occasional accident

10 = continent ______

BLADDER

0 = incontinent, or catheterized and unable to manage alone

5 = occasional accident

10 = continent ______

TOILET US E

0 = dependent

5 = needs some help, but can do something alone

10 = independent (on and off, dressing, wiping) ______

TRANSFERS (BED TO CHAIR AND BACK)

0 = unable, no sitting balance

5 = major help (one or two people, physical), can sit

10 = minor help (verbal or physical)

15 = independent ______

MOBILITY (ON LEVEL S URFACES)

0 = immobile or < 50 yards

5 = wheelchair independent, including corners, > 50 yards

10 = walks with help of one person (verbal or physical) > 50 yards

15 = independent (but may use any aid; for example, stick) > 50 yards ______ STAIRS

0 = unable

5 = needs help (verbal, physical, carrying aid)

10 = independent ______

TOTAL (0–100): ______

3、格拉斯哥昏迷量表（Glasgow Coma Scale）

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Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment. A patient is assessed against the criteria of the scale, and the resulting points give a patient score between 3 (indicating deep unconsciousness) and either 14 (original scale) or 15 (the more widely used modified or revised scale).

GCS was initially used to assess level of consciousness after head injury, and the scale is now used by first aid, EMS, and doctors as being applicable to all acute medical and trauma patients. In hospitals it is also used in monitoring chronic patients in intensive care.

The scale was published in 1974 by Graham Teasdale and Bryan J. Jennett, professors of neurosurgery at the University of Glasgow's Institute of Neurological Sciences at the city's Southern General Hospital.

GCS is used as part of several ICU scoring systems, including APACHE II, SAPS II, and SOFA, to assess the status of the central nervous system. A similar scale, the Rancho Los Amigos Scale is used to assess the recovery of traumatic brain injury patients.

Elements of the scale

Glasgow Coma Scale

1 2 3 4 5 6

Eyes Does

not

open

eyes

Opens eyes in

response to

painful

stimuli

Opens eyes

in

response

to voice

spontaneo

usly

Verb al Makes

no

sounds

Incomprehens

ible sounds

Utters

inappropr

iate words

disorient

ed

Moto r Makes

no

Extension to

painful

Abnormal

flexion to

Flexion /

Withdrawa

Locali

zes

Obeys

comman

moveme nts

stimuli

(decerebrate

response)

painful

stimuli

(decortic

ate

response)

l to

painful

stimuli

painfu

l

stimul

i

ds

The scale comprises three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person). Best eye response (E)

There are 4 grades starting with the most severe:

1.No eye opening

2.Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernail

bed; if this does not elicit a response, supraorbital and sternal pressure or rub may be

used.)

3.Eye opening to speech. (Not to be confused with an awaking of a sleeping person; such

patients receive a score of 4, not 3.)

4.Eyes opening spontaneously

[edit] Best verbal response (V)

There are 5 grades starting with the most severe:

1.No verbal response

2.Incomprehensible sounds. (Moaning but no words.)

3.Inappropriate words. (Random or exclamatory articulated speech, but no conversational

exchange)

4.Confused. (The patient responds to questions coherently but there is some disorientation

and confusion.)

5.Oriented. (Patient responds coherently and appropriately to ques tions such as the patient’s

name and age, where they are and why, the year, month, etc.)

[edit] Best motor response (M)

There are 6 grades starting with the most severe:

1.No motor response

2.Extension to pain (abduction of arm, internal rotation of shoulder, pronation of forearm,

extension of wrist, decerebrate response)

3.Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of

forearm, flexion of wrist, decorticate response)

4.Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist

when supra-orbital pressure applied ; pulls part of body away when nailbed pinched)

5.Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crosses

mid-line and gets above clavicle when supra-orbital pressure applied.)

6.Obeys commands. (The patient does simple things as asked.)

[edit] Interpretation

Individual elements as well as the sum of the score are important. Hence, the score is expressed in the form "GCS 9 = E2 V4 M3 at 07:35".

Generally, brain injury is classified as:

?Severe, wit h GCS ≤ 8

?Moderate, GCS 9 - 12

?Minor, GCS ≥ 13.

Tracheal intubation and severe facial/eye swelling or damage make it impossible to test the verbal and eye responses. In these circumstances, the score is given as 1 with a modifier attached e.g. 'E1c' where 'c' = closed, or 'V1t' where t = tube. A composite might be 'GCS 5tc'. This would mean, for example, eyes closed because of swelling = 1, intubated = 1, leaving a motor score of 3 for 'abnormal flexion'. Often the 1 is left out, so the scale reads Ec or Vt.

The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). Consequently the Pediatric Glasgow Coma Scale, a separate yet closely related scale, was developed for assessing younger children.

[edit] Revisions

?Glasgow Coma Scale: While the 15 point scale is the predominant one in use, this is in fact a modification and is more correctly referred to as the Modified Glasgow Coma Scale.

The original scale was a 14 point scale, omitting the category of 'abnormal flexion'. Some centres still use this older scale, but most (including the Glasgow unit where the original

work was done) have adopted the modified one.

?The Rappaport Coma/Near Coma Scale made other changes.

[edit] See also

?Blantyre Coma Scale

?Rancho Los Amigos Scale

?Paediatric Glasgow Coma Scale

?Revised Trauma Score

4、美国国立卫生研究院卒中量表（NIH Stroke Scale，NIHSS）

5、斯堪的那维亚卒中量表（Scandinavian Stroke Scale，SSS）

6、欧洲卒中量表（The European Stroke Scale,ESS）

7、中国脑卒中临床神经功能缺损程度评分量表（1995）

8、HAMILTON抑郁量表-21项评分标准

9、HAMILTON焦虑量表