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Signs and Scales
Chapter 9
Red book
Signs
Warnings that something is wrong
Characteristics with specific meaning because the phenomenon they
represent has been studied extensively.
Vital Signs
 Made up of four measures
Blood pressure
2. Pulse rate
3. Temperature
4. Respiration rate
1.
PERRLA
 The abbreviation used when noting that an individual’s eyes and
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pupil reaction are within normal limits
Eyes and pupils that don’t react within normal limits may indicate
neurological damage, eye infection, glaucoma, or the effects of
certain drugs
P - Pupils
E – Equal
R - Round
R – React to...
L - Light
A – Accommodating
 (constrict when changing focus from distant object to close object)
Signs of Edema
 Edema
 Excess intracellular (between cells) or interstitial (between
tissues) fluid
 Body is not able to get rid of excess fluid appropriately
 Signs of Edema
 Requires palpitation of the skin (usually lower leg or ankle area)
 Gently press down on client’s skin, enough to cause a slight
indentation
 Maintain pressure for five seconds, then remove your finger
 If indentation remains, that is a sign of edema
 Will also appear taut, shiny, and swollen
Scales
A method of measuring “where” or “how much” something is in
relationship to the scope of possibilities using commonly recognized
increments
Scale Structures
 Nominal
 Groups pieces of information into categories that are similar in nature
 There is no linear relationship to the different categories
 Examples: Gender, title, Disability type, football jersey numbers
 Ordinal
 Groups information into categories that are similar in nature and have a
relative, but not exactly defined, progression from less to more
 Example: Likert Scale
 Interval
 A scale in which each level is clearly defined and the increments
between the levels are equal.
 Examples: ROM, distance, temperature
American Spinal Injury
Association Impairment Scale (AIS)
 Measures the severity of a spinal cord injury
 Classification system has five levels of completeness (A through E)
 Table 9.5 pg. 183
 The level of the spinal cord injury is determined by the nerve(s)
injured, not the vertebrae involved.
 Nerves are classified according to the level of the cord at which they emerge
 The AIS also measures the completeness of the injury
Scales for predicting pressure ulcer score
risk and stages of skin breakdown
 Decubitus ulcers are graded on a four-point scale
 Figure 9.1, pg. 184
 Braden Scale for Predicting Pressure Ulcer Sore Risk
 Internationally recognized scale that predicts a client’s chances of
developing a decubitus ulcer.
 Table 9.6, pg. 185
Brief Cognitive Rating Scale (BCRS)
 A quick assessment of a client’s level of impairment due to dementia
 Contains five subsections, called Axes
 Concentration
 Impairment of recent memory
 Impairment of past memory
 Orientation
 Functioning and Self-care
 Table 9.7, pg. 186-187
 Each Axis is scored on a seven point ordinal scale
 Global Deterioration Scale (GDC) also measures level of dementia
Checklist of Nonverbal Pain Indicators
 CNPI measures pain in clients with cognitive impairments
 Table 9.8, pg. 188
 Best used when the client is moving about and engaging in
activity
FACES Pain Rating Scale
 Originally developed to measure the severity of a child’s pain
 Other pain scales use ten choices, this uses a scale of six (no
pain, plus a scale of five)
 Figure 9.2, Pg. 189
 An accepted modification of this scale is to convert to a 0-10
point scale using the numbers 0, 2, 4, 6, 8, 10.
 JCAHO recommends using the 10 point scale with adult
populations
FIM
 Functional Independence Measure
 Seven level scale that helps measure performance
 NOT a standardized testing tool, although many standardized
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tools have integrated the FIM within their tool
Interdisciplinary reporting tool used to measure outcomes of
rehab. therapies for individuals with spinal cord injuries.
Seven point scale that measures the degree of assistance an
individual requires to complete a task
Therapist is required to take an approved training course to use
– AND- facility is required to have permission to use the scale
Table 9.9, pg. 190
Glasgow Coma Scale and Children’s
Coma Scale
 GCS and CCS are two scales developed to measure the depth
of a coma
 GCS used with older children and adults
 CCS used with children under 3 years of age.
 Each scale has three sections
 Eye responses
 Motor responses
 Verbal responses
 Table 9.10, pg 191
Global Assessment of Functioning
Scale (GAF)
 Describes a person’s combined psychological, social, and
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occupational well-being
Ranges from 1 (death) to 100 (total absence of mental or
physical problems)
Copyright belongs to APA
However the reading of the scale is not limited by copyright
and its used throughout the world
Table 9.11, pg. 191
But what about the GAF now?
http://www.dsm5.org/Documents/FAQ%20for%20Clinicians%208-1-13.pdf
Global Deterioration Scale (GDS)
 Used with clients with a primary diagnosis of Dementia
 Seven level scale
 Individuals in stages 1-4 are commonly thought to be able to
still live in the community independently.
 Table 9.12, pg. 192
 Should only be used as a quick description of client’s current
level of ability
 Brief Cognitive Rating Scale (BCRS) is more accurate
assessment of dementia
 BCRS scores correspond with GDS scores
Hearing Loss
 Measured in decibels
 Six standard levels to describe the range
1.
2.
3.
4.
5.
6.
Normal
Mild
Moderate
Moderate/Severe
Severe
Profound
Intelligence Quotient (IQ)
 Numerical scores from 0-200
 Ten levels
 Table 9.13, Pg. 194
Mental Status Exam
 The Mental Status Exam (MSE) is the psychological
equivalent of a physical exam that describes the mental state
and behaviors of the person being seen. It includes both
objective observations of the clinician and subjective
descriptions given by the patient.
 http://www.dshs.wa.gov/manuals/socialservices/sections/
MSE_GUIDELINES.shtml
Mini-Mental State Examination
 MMSE or Folstein test.
 Widely used to determine cognitive impairment
 Measures ability in a broad scope of skills
 Including
 Orientation to date
 Short term memory
 Attention
 Calculation
 Recall
 Language
 Following three step commands
 Simple writing skills
 Simple test of spatial drawing skills
Multiaxial Assessment
 Five category reporting system used by psychiatrists and clinical
psychologists
 Not a true scale
 Used to ensure that an individual’s degree of health in five domains
is considered prior to diagnosis and treatment
 APA publishes DSM-IV-TR
 Provides criteria for determining psychiatric conditions
 Psychological disorders fall into first two axes
 Remaining axes cover
 Individual’s general medical condition
 Psychosocial and environmental problems experienced by the individual
 Individual’s overall function
 Table 9.14, pg. 195
What about the 5 axes now?
http://www.dsm5.org/Documents/FAQ%20for%20Clinicians%208-1-13.pdf
Muscle Strength
 Numerous six point scales, with corresponding levels, used
to measure muscle strength
 Table 9.16, pg. 197
Orientation x 3
 General term used to express whether the client is oriented
to:
 Time
 Person
 Place
 Example bottom right of pg. 197
Rancho Los Amigos Scale
 8 level ordinal scale used to indentify the level of cognitive
disability as a result of brain trauma
 Table 9.17, pg. 198
ROM
 Range of Motion
 Multiple scales
 Each joint in the body has its own scale that measures the
degree of flexibility for that joint
 ROM measures the maximum extension of a joint to the
maximum flexion of a joint and is reported by using the
degrees in a circle.
 Goniometer is the tool that measures ROM.
 Table 9.18, pg. 198 describes the standard measurements of
ROM
Sedation Scale
 Part of the score sheet used with the FACES scale
 Normally you wouldn’t be evaluating sedation of a client, but
it is good to be aware of in case you come into a room of a
patient who has been over sedated.
 Table 9.19, pg. 199
Three Step Command
 Not a formal scale
 But a commonly used ordinal scale to describe a client’s observed
performance in short-term memory
 One step command
 Two step command
 Three step command
 Tasks associated with three step command are not nationally
standardized
 Good idea to standardize within facility
Visual Disability Rating Levels Scale
 How well an individual can see things at a distance
 20/20 = normal vision
 Top number is location of person taking the test
 Bottom number is how well the person can see compared to the
average population
 20/15 means the person can see from 20 feet what the average
person can see from 15 feet.
 Better than average
 20/200 means the person can see from 20 feet what the average
person can see from 200 feet
 Worse than average