Clinical Assessment Tools
Glasgow Coma Scale (GCS)
| Response | Score |
|---|---|
| Eye Opening | |
| Spontaneous | 4 |
| To speech | 3 |
| To pain | 2 |
| None | 1 |
| Verbal | |
| Oriented | 5 |
| Confused | 4 |
| Inappropriate words | 3 |
| Incomprehensible sounds | 2 |
| None | 1 |
| Motor | |
| Obeys commands | 6 |
| Localizes pain | 5 |
| Withdraws from pain | 4 |
| Flexion to pain | 3 |
| Extension to pain | 2 |
| None | 1 |
Total score 3–15. <8 = severe TBI; 9–12 = moderate; 13–15 = mild.
APGAR Score
| Sign | 0 | 1 | 2 |
|---|---|---|---|
| Appearance (skin color) | Blue, pale | Body pink, extremities blue | Completely pink |
| Pulse (heart rate) | Absent | <100 bpm | ≥100 bpm |
| Grimace (reflex irritability) | No response | Grimace | Cough, sneeze, cry |
| Activity (muscle tone) | Limp | Some flexion | Active motion |
| Respiration | Absent | Slow, irregular | Good, crying |
Assessed at 1 and 5 minutes. 7–10: good; 4–6: moderate distress; 0–3: severe distress.
Pain Scales
- Numeric (0–10): Patient rates pain 0 (no pain) to 10 (worst).
- Wong-Baker FACES: Faces scale for children and those who prefer visual.
- FLACC: Face, Legs, Activity, Cry, Consolability — for preverbal/young children.
- CPOT: Critical-Care Pain Observation Tool — for intubated/unable to self-report.
Braden Scale
| Category | 1 (worst) | 2 | 3 | 4 (best) |
|---|---|---|---|---|
| Sensory Perception | Completely limited | Very limited | Slightly limited | No impairment |
| Moisture | Constantly moist | Often moist | Occasionally moist | Rarely moist |
| Activity | Bedfast | Chairfast | Walks occasionally | Walks frequently |
| Mobility | Completely immobile | Very limited | Slightly limited | No limitations |
| Nutrition | Very poor | Probably inadequate | Possibly adequate | Excellent |
| Friction/Shear | Problem | Potential problem | — | No apparent problem |
Total 6–23. ≤18 = at risk for pressure injury.
Morse Fall Scale
| Item | Score |
|---|---|
| History of falling (no/yes) | 0 / 25 |
| Secondary diagnosis (no/yes) | 0 / 15 |
| Ambulatory aid (none/crutch/cane/walker/furniture) | 0 / 15 / 15 / 15 / 30 |
| IV/heparin lock (no/yes) | 0 / 20 |
| Gait (normal/weak/impaired) | 0 / 10 / 20 |
| Mental status (oriented/overestimates/forgets) | 0 / 15 / 15 |
≥45 = high risk for falls.
NIH Stroke Scale
11-item neurologic assessment. Categories: Level of consciousness, Best gaze, Visual fields, Facial palsy, Motor arm, Motor leg, Limb ataxia, Sensory, Language, Dysarthria, Extinction/inattention.
Score range 0–42. Higher = more severe deficit. Used to quantify stroke severity and guide treatment.