Workshop on BLS,ACLS

AND ECG Interpretation

Dr. Deepakkumar K.Ukey

ASSESSMENT
TOOLS

What are Assessment

Scales?
Assessment Scales are used to adequately

measure the degree of a patients 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 patients treatment

Assessment tools [In MAX

Hospital]
Apgar Score
Pain score a]VAS
b]FLACC
Ramsey score
SOFA score
GCS
Morse fall risk score
Braden score
VIP Score
FAST scale

APGAR SCORE

APGAR SCORE

APGAR TEST

What is it?
A test developed in 1952 by Dr.
Virginia Apgar
A babys first test
Quick assessment of the
newborns overall well-being
Given one-minute after birth and
five minutes after birth
Rates 5 vital areas

Why to be
done ??

To assess the babys vital

signs quickly
The score is helpful for later
evaluations
Its fun and interesting for the
parents

The 5 Signs:

1.color
a. Pale or blue = 0
b. Normal color
body, but blue
extremities
(arms and/or
legs) = 1
c. Normal color =
2 completely
pink

2.Respiratio
n

a. Not breathing = 0
b. Weak cry,
irregular breathing =
1
c. Strong cry = 2
2 points for a strong
cry
1 point for a slow or
weak cry
0 points for no cry at

3. The babys
heart rate

a. Absent heartbeat = 0
b. Slow heartbeat (less than 100
beats/minute) = 1
c. Adequate heartbeat (more than 100
beats/minute) = 2
2 = good strong heartbeat
1 = slow but steady heartbeat
0 = little or no heartbeat

4. The babys muscle

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

2
1
0

points for vigorous motion

point for small flexing
points for no movement

5. The babys
reflexes

Response to Stimulation (also

called Reflex Irritability):
a. No response = 0
b. Grimace (facial expression) = 1
c. 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

Result
s

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 babys
long-term behavior
Parents should not
put too much
emphasis on the
score as a future
predictor of the
babys intellectual
or physical
performance

PAIN
ASSESSMENT
TOOLS
15

PAIN ASSESSMENT TOOLS

VAS
SCAL
E
16

FLAC
C
SCAL
E

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 010 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 SCALE
Face

Legs

No particular expression or smile

Occasional grimace or frown,

withdrawn or disinterested

Frequent to constant quivering

chin, clenched jaw

Normal position or relaxed

Uneasy, restless, tense

Kicking or legs drawn up

Activity

Cry

Lying quietly, normal position,

moves easily

No cry (awake or sleep)

Squirming, shifting back & forth,

tense

Moans or whimpers, occasional

complaint

Arched, rigid or jerking

Crying steadily, screams or sobs,

frequent complaints

Consolability
Content, relaxed

Reassured by occasional touching,

hugging or being talked to,
distractible

Difficult to console or comfort

RAMSEY
SEDATION
SCALE
21

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

MORSE FALL RISK

ASSESSMENT TOOL

24

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 patients
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
History of fall
Secondary diagnosis

Ambulatory aid

IV/ Heparin lock

Gait Transferring

Mental status

Scale

Points

Yes

25

No

Yes

15

No

Furniture

30

Crutches/walker/cane

15

None/bed rest/wheelchair/nurse

Yes

20

No

Impaired

20

Weak

10

Normal/bed rest/immobile

Forgets limitation

15

Oriented to own ability

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/Cardiova
scular agent/ B-Blockers
Cathartic/laxative
Diuretic
Pain medication
Sedative &
Benzodiazepine

SOFA SCORE

28

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

NEROLOGY
SYSTEM

13 14
1
10 12
2
69
3
<6

SOFA

30

SOFA SCORE
CARDIO VASCULAR
SYSTEM
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) [mol/L]

(or urine output)

RENAL SYSTEM

SOFA score
1.2 1.9 [110 170/d]
2.0 3.4 [171 299/d]

1
2

3.5 4.9 [300 - 440] (or < 500

ml/d)
3
> 5.0 [>440] (or < 200 ml/d)
4
31

SOFA SCORE
Bilirubin (mg/dl) [mol/L]
SOFA score

LIVER

1.2 1.9 [>20.5 - 32.5]

1
2.0 5.9 [34.2 - 100.9]

6.0 11.9 [102.6 - 203]

> 12.0 [>205]

4

COAGULATI
ON

Platelets103/mcl
SOFA score
<
1
<
2
<
3
<
4

150
100
50
20
32

GLASGOW
COMA SCALE
33

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 912 (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).

BRADEN SCALE

37

VIP SCORE

39

VIP SCORE

40

FAST SCALE

41

FAST (stroke)
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 42
stroke, and an

FAS SCALE IN STROKE

Fa c i a l D r o o p ( h a v e p a t i e n t s m i l e )
Normal: Both sides of face move equally
Abnormal: 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 all
Abnormal: 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
slurring
43
Abnormal: Slurred or inappropriate words, or

44