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 DESCRIPTION0 No symptoms at all1 No significant disability despite symptoms; able to carry out all usual duties and activities2 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance3 Moderate disability; requiring some help, but able to walk without assistance4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention6 DeadScores:0-62、日常生活能力量表－巴氏指数（Barthel Index）THE Patient Name: ___________________________BARTHEL Rater Name: ___________________________ INDEX Date: ___________________________Activity ScoreFEEDING0 = unable5 = needs help cutting, spreading butter, etc., or requires modified diet10 = independent ______BATHING0 = dependent5 = independent (or in shower) ______GROOMING0 = needs to help with personal care5 = independent face/hair/teeth/shaving (implements provided) ______ DRESSING0 = dependent5 = needs help but can do about half unaided10 = independent (including buttons, zips, laces, etc.) ______BOWELS0 = incontinent (or needs to be given enemas)5 = occasional accident10 = continent ______BLADDER0 = incontinent, or catheterized and unable to manage alone5 = occasional accident10 = continent ______TOILET US E0 = dependent5 = needs some help, but can do something alone10 = independent (on and off, dressing, wiping) ______TRANSFERS (BED TO CHAIR AND BACK)0 = unable, no sitting balance5 = major help (one or two people, physical), can sit10 = minor help (verbal or physical)15 = independent ______MOBILITY (ON LEVEL S URFACES)0 = immobile or < 50 yards5 = wheelchair independent, including corners, > 50 yards10 = walks with help of one person (verbal or physical) > 50 yards15 = independent (but may use any aid; for example, stick) > 50 yards ______ STAIRS0 = unable5 = needs help (verbal, physical, carrying aid)10 = independent ______TOTAL (0–100): ______3、格拉斯哥昏迷量表（Glasgow Coma Scale）From Wikipedia, the free encyclopediaJump to: navigation, searchGlasgow 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 scaleGlasgow Coma Scale1 2 3 4 5 6Eyes DoesnotopeneyesOpens eyes inresponse topainfulstimuliOpens eyesinresponseto voicespontaneouslyVerb al MakesnosoundsIncomprehensible soundsUttersinappropriate wordsdisorientedMoto r MakesnoExtension topainfulAbnormalflexion toFlexion /WithdrawaLocalizesObeyscommanmoveme ntsstimuli(decerebrateresponse)painfulstimuli(decorticateresponse)l topainfulstimulipainfulstimulidsThe 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 opening2.Eye opening in response to pain. (Patient responds to pressure on the patient’s fingernailbed; if this does not elicit a response, supraorbital and sternal pressure or rub may beused.)3.Eye opening to speech. (Not to be confused with an awaking of a sleeping person; suchpatients 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 response2.Incomprehensible sounds. (Moaning but no words.)3.Inappropriate words. (Random or exclamatory articulated speech, but no conversationalexchange)4.Confused. (The patient responds to questions coherently but there is some disorientationand confusion.)5.Oriented. (Patient responds coherently and appropriately to ques tions such as the patient’sname 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 response2.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 offorearm, flexion of wrist, decorticate response)4.Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wristwhen supra-orbital pressure applied ; pulls part of body away when nailbed pinched)5.Localizes to pain. (Purposeful movements towards painful stimuli; e.g., hand crossesmid-line and gets above clavicle when supra-orbital pressure applied.)6.Obeys commands. (The patient does simple things as asked.)[edit] InterpretationIndividual 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 originalwork 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 Score4、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。