ICU (scorings)

18 0 0
                                    

Glasgow Coma Scale (Behavior Score)


Eye Opening (E)4 Spontaneous 3 To verbal stimuli 2 To pain 1 None


Motor Response (M)6 Obeys commands 5 Localizes pain 4 Withdraws to pain 3 Abnormal flexion 2 Extensor response 1 None


Verbal Response (V)5 Oriented 4 Confused 3 Inappropriate words 2 Incomprehensible sounds 1 None 


Edema Rating ScaleFollowing the application and removal of firm digital pressure against thetissue, the edema is evaluated for one of the following responses:• 0 No depression in tissue• 1 Small depression in tissue, disappearing in 1 second• 2 Depression in tissue disappears in 1-2 second• 3 Depression in tissue disappears in 2-3 second• 4 Depression in tissue disappears in 4 second


Peripheral Pulse Rating Scale• 0 Absent pulse• 1 Palpable but thready; easily obliterated with light pressure• 2 Normal; cannot obliterate with light pressure• 3 Full• 4 Full and bounding


Cranial Nerve Function

I. Olfactory Sense of smell

II. Optic Visual fields, visual acuity

III. Oculomotor Most extraocular eye movements, ability to elevate eyelid, muscular contraction

of the iris in response to light

IV. Trochlear Eye movement down and toward the nose

V. Trigeminal Facial sensation, including cornea, nasal mucosa, and oral mucosa; muscles

of chewing and mastication

VI. Abducens Lateral eye movement

VII. Facial Facial muscles, including eyelid closure; taste in anterior two thirds of the tongue; secretion

of saliva and tears

VIII. Acoustic Hearing and equilibrium

IX. Glossopharyngeal Gag reflex, muscles that control swallowing and phonation; taste in posterior third of tongue

X. Vagus (overlapping Salivary gland secretion; vagal control of heart,

innervation) lungs, and gastrointestinal tract

XI. Spinal accessory Sternocleidomastoid and trapezius muscle strength

XII. Hypoglossal Tongue movement

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