Workshop on BLS,ACLS AND ECG Interpretation

Dr. Deepakkumar K.UkeyASSESSMENT

TOOLS

What are Assessment Scales?

Assessment Scales are used to adequately measure the degree of a patient’s pain, (dis)comfort or to examine mental

status. In the case where the patient is unable to communicate effectively, the observation-based scales offer

an objective measurement tool to support the medical professional in his/her decision for the most appropriate

patient’s treatment

Assessment tools [In MAX Hospital]

Apgar ScorePain score –a]VAS b]FLACCRamsey scoreSOFA scoreGCSMorse fall risk scoreBraden scoreVIP ScoreFAST scale

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APGAR SCORE

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APGAR SCORE

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APGAR TEST

• A test developed in 1952 by Dr. Virginia Apgar

• A baby’s first test• Quick assessment of the newborn’s

overall well-being• Given one-minute after birth and five

minutes after birth• Rates 5 vital areas

• To assess the baby’s vital signs quickly

• The score is helpful for later evaluations

• It’s fun and interesting for the parents

Why to be done ??

What is it?

The 5 Signs:

a. Pale or blue = 0b. Normal color body,

but blue extremities (arms and/or legs) = 1

c. Normal color = 2 – completely pink

1.colora. Not breathing = 0b. Weak cry, irregular breathing = 1c. Strong cry = 2

2 points for a strong cry1 point for a slow or weak cry0 points for no cry at all

2.Respiration

3. The baby’s heart rate

a. Absent heartbeat = 0b. Slow heartbeat (less than 100 beats/minute) = 1c. Adequate heartbeat (more than 100 beats/minute)

= 2

• 2 = good strong heartbeat• 1 = slow but steady heartbeat• 0 = little or no heartbeat

4. The baby’s muscle tone

a. Limp, flaccid = 0b. Some flexing or bending = 1c. Active motion = 2

• 2 points for vigorous motion• 1 point for small flexing• 0 points for no movement

5. The baby’s reflexes

Response to Stimulation (also called Reflex Irritability):

a. No response = 0b. Grimace (facial expression) = 1c. Vigorous cry or withdrawal = 2

• 2 points if the baby cries• 1 point if the baby grimaces (facial expression)• 0 points for no movement or sound

Results

• 10 out of 10 is a perfect score• The higher the score, the better the

condition• A score over 7 indicates good condition• A score of 10 is unusual• A score less than 7 may indicate some

medical assistance

Limits

• Quick assessment• Does not necessarily

indicate a baby’s long-term behavior

• Parents should not put too much emphasis on the score as a future predictor of the baby’s intellectual or physical performance

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PAIN ASSESSMENT

TOOLS

PAIN ASSESSMENT TOOLS

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VAS SCALE

FLACC SCALE

VISUAL ANALOGUE SCALE

FLACC SCALE

FLACC stands for face, legs, activity, crying and consolability. It is an observer rated pain scale, performed by a healthcare practitioner such as a doctor or a nurse. The FLACC pain scale was designed for children between the ages of 2 and 7. However, some practitioners in adult settings may use the FLACC pain scale for people who are unable to communicate their pain. FLACC provides a pain assessment scale between 0 and 15.

FLACC SCALE

The Face, Legs, Activity, Cry, Consolability scale or FLACC scale is a measurement used to assess pain for children between the ages of 2 months–

7years or individuals that are unable to communicate their pain. The scale is scored

between a range of 0–10 with 0 representing no pain. The scale has 5 criteria which are each

assigned a score of 1, 2 or 3.

The FLACC scale has also been found to be accurate for use with adults in intensive-care units (ICU) who

are unable to speak due to intubation. The FLACC scale offered the same evaluation of pain as did the Checklist of Nonverbal Pain Indicators (CNPI) scale

which is used in ICUs.[2]

FLACC SCALEFace

No particular expression or smile 1

Occasional grimace or frown, withdrawn or disinterested

2

Frequent to constant quivering chin, clenched jaw

3

Legs

Normal position or relaxed 1

Uneasy, restless, tense 2

Kicking or legs drawn up 3

Activity

Lying quietly, normal position, moves easily

1

Squirming, shifting back & forth, tense

2

Arched, rigid or jerking 3

Cry

No cry (awake or sleep) 1

Moans or whimpers, occasional complaint

2

Crying steadily, screams or sobs, frequent complaints

3

Consolability

Content, relaxed 1

Reassured by occasional touching, hugging or being talked to,

distractible

2

Difficult to console or comfort 3

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RAMSEY

SEDATION SCALE

RAMSEY SEDATION SCALE

The Ramsay Sedation Scale (RSS, Table), was the first scale to be defined and was designed as a test of rousability. The RSS scores sedation at six different levels, according to how rousable the patient is. It is an intuitively obvious scale and therefore lends itself to universal use, not only in the ICU, but wherever sedative drugs or narcotics are given. It can be added to the pain score and be considered the sixth vital sign.

RAMSAY SEDATION SCORE

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MORSE FALL RISK ASSESSMENT TOOL

FALL RISK ASSESSMENT

Fall risk assessment will be carried out every 24 hours for all patients getting admitted at MHC units. In case of High

risk patients, it should be carried out in each and every shift.

Patients should be assessed immediately for their fall risk:

On admission to the facility

On any transfer from one unit to another within the facility

Following any change in patient’s physical/mental status

Following a fall

FALL RISK ASSESSMENT (CONT…)

When patient is started on one or more of

following medications:

- Anesthetics - Antiepileptic - Antihistaminics - Antihypertensive/Cardiovascular agent/ B-Blockers - Cathartics/laxatives - Diuretics - Pain medications - Sedatives & Benzodiazepines

MORSE FALL RISK ASSESSMENT

Risk factor Scale Points

History of fall Yes 25

No 0

Secondary diagnosis Yes 15

No 0

Ambulatory aidFurniture 30

Crutches/walker/cane 15

None/bed rest/wheelchair/nurse 0

IV/ Heparin lock Yes 20

No 0

Gait TransferringImpaired 20

Weak 10

Normal/bed rest/immobile 0

Mental status Forgets limitation 15

Oriented to own ability 0

High risk = 45 & above Moderate Risk = 25-44 Low Risk = 0-24

Fall risk assessment to be done when the patient is started on the following and then every 24 hrs. Anesthetic Antiepileptic Antihistamine Antihypertensive/

Cardiovascular agent/ B-Blockers

Cathartic/laxative Diuretic Pain medication Sedative &

Benzodiazepine

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SOFA SCORE

SEQUENTIAL ORGAN FAILURE ASSESSMENT SCORE [SOFA ] …)

The Sequential Organ Failure Assessment score, or just SOFA score, is used to track a patient's status during the stay in an intensive care unit (ICU). It is one of several ICU scoring systems.

The SOFA score is a scoring system to determine the extent of a person's organ function or rate of failure.[1][2][3][4][5] The score is based on six different scores, one each for the respiratory, cardiovascular, hepatic, coagulation, renal and neurological systems.

Both the mean and highest SOFA scores being predictors of outcome. An increase in SOFA score during the first 24 to 48 hours in the ICU predicts a mortality rate of at least 50% up to 95%. Scores less than 9 give predictive mortality at 33% while above 11 can be close to or above 95%

SOFA SCORE

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PaO2/FiO2 (mmHg) SOFA score < 400 - 1 < 300 - 2 < 200 and mechanically ventilated - 3 < 100 and mechanically ventilated - 4

GCS SOFA score 13 – 14 1 10 – 12 2 6 – 9 3 < 6 4

RESPIRATORY SYSTEM

NEROLOGY SYSTEM

SOFA SCORE

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SCORE MAP < 70 mm/Hg 1 dop <= 5 or dob (any dose) 2 dop > 5 OR epi <= 0.1 OR nor <= 0.1 3 dop > 15 OR epi > 0.1 OR nor > 0.1 4

(vasopressin drug doses are in mcg/kg/min)

Creatinine (mg/dl) [μmol/L] (or urine output) SOFA score

1.2 – 1.9 [110 – 170/d] 1 2.0 – 3.4 [171 – 299/d] 2 3.5 – 4.9 [300 - 440] (or < 500 ml/d) 3 > 5.0 [>440] (or < 200 ml/d) 4

CARDIO VASCULAR SYSTEM

RENAL SYSTEM

SOFA SCORE

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Bilirubin (mg/dl) [μmol/L] SOFA score

1.2 – 1.9 [>20.5 - 32.5] 1

2.0 – 5.9 [34.2 - 100.9] 2

6.0 – 11.9 [102.6 - 203] 3

> 12.0 [>205] 4

Platelets×103/mcl SOFA score

< 150 1 < 100 2 < 50 3 < 20 4

LIVER

COAGULATION

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GLASGOW COMA SCALE

Glasgow coma scale

The 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.

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.

• 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 Opens eyes spontaneously N/A N/A Verbal Makes no sounds Incomprehensible sounds Utters inappropriate words Confused, disoriented Oriented, converses normally N/A Motor Makes no movements Extension to painful stimuli (decerebrate response) Abnormal flexion to painful stimuli (decorticate response) Flexion / Withdrawal to painful stimuli Localizes painful stimuli Obeys commands

GCS contd……………………

• 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, with GCS < 9 • Moderate, GCS 9–12 (controversial) reference • Minor, GCS ≥ 13. • The scale is composed of 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).

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BRADEN SCALE

Braden Risk Scale:A. Sensory

Perception

B. Moisture C. Activity D. Mobility E. Nutrition F. Shear

1.Completely Ltd.

2.Very Ltd.

3.Slightly Ltd.

4.No Impairment

Constantly moist

Very Moist

Occasionally Moist

Rarely Moist

Confined to bed

Unable to bearown wt.

Walks occasionally

Walks Frequently

Unable

Occasional

Moves extremity

Changes positionindependently

Very poor

Inadequate

Adequate

Excellent

Problem

Potential Problem

No Apparent Problem

(15 or 16 = Low Risk , 13 or 14 =moderate risk, 12 or less = high risk)

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VIP SCORE

VIP SCORE

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FAST SCALE

FAST (stroke)

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FAST is an acronym used to help detect and enhance responsiveness to stroke victim needs. The acronym stands for Facial drooping, Arm weakness, Speech difficulties and Time

Facial drooping: A section of the face, usually only on one side, that is drooping and hard to move

Arm weakness: The inability to raise one's arm fully

Speech difficulties: An inability or difficulty to understand or produce speech

Time: Time is of the essence when having a stroke, and an immediate call to emergency services or trip to the hospital is recommended.

FAS SCALE IN STROKE

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F a c i a l D r o o p ( h a v e p a ti e n t s m i l e )Normal: Both sides of face move equallyAbnormal: One side of face does not move as well

Arm Drift (have patient hold arms out for 10 seconds)Normal: Both arms move equally or not at allAbnormal: One arm drifts compared to the other, or does not move at all

Speech (have patient speak a simple sentence)Normal: Patient uses correct words with no slurringAbnormal: Slurred or inappropriate words, or mute

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