Scales NPTE

MMT Grade 0 to 3

0: None

1: Trace contraction

2-: < Full ROM Gravity Eliminated

2: Full ROM Gravity Eliminated

2+: <1/2 of ROM against gravity

3-: >1/2 ROM against gravity,

MMT Grade 3 to 5

3: Full ROM against Gravity

3+: Full ROM, holds against slight resistance

4-: Holds against mild resistance: breaks against mod

4: Holds against moderate resistance, Breaks against Mod Plus resistance

4+: Holds against Mod Plus resistance, Breaks against max

5: Holds against max resistance

Reflex Grades

Normal Reflex grade?

0: None

1+: Decreased

2+: Normal

3+: Slightly Hyperactive

4+: Hyperactive

Glasgow Scale

Sever TBI: 0 to 8

Mod TBI: 9 to 12

Mild TBI: 13 to 14

Normal: 15

3 Categories of scoring Glasgow Scale

1: Eye Opening

2: Motor Response

3: Verbal Response

Post Traumatic Amnesia Times: Level of TBI

Less than 1 Day: Mild

1 to 7 Days: Moderate

>7 Days: Severe

LOC Times: Level of TBI

0 to 30 Min: Mild

30 Min to 24 Hrs: Moderate

>24 Hours: Severe

What Scale is used to assess Pressure Ulcer Risk?

Braden Scale

Braden Scale Cutpoints

Mild Risk: 15 to 18

Mod Risk: 13 to 14

High Risk: 10 to 12

Very High Risk: 9 or less

* Risk of developing pressure ulcer

* Range: 6 to 23

Pressure Ulcer Stages:

1: Redness of skin, no open wound

2: Open wound, Restricted to Skin only

3: Extends into subcutaneous fat, No Muscle or Bone

4: Extends into Muscle and bone

What Scale is used to assess Neuropathic Ulcers?

Wagner

Wagner Scale:

0: Skin intact

1: Superficial ulcer to Subcutaneous Tissue (Skin)

2: Ulcer Extends into Tendon and Bone (Deep)

3: Deep Ulcer w/ Osteomyelitis or Abscess (Infection)

4: Gangreen of Toes/ forefoot

5: Gangreen extending into Midfoot to hindfoot

Burn Degree's

1st Degree: (superficial) Only Damage to epidermis

2nd Degree: (superficial patial thickness) Involves superficial dermis. Painful, blanches

2nd Degree: (deep partial thickness) involves deep dermis. minimal pain (decreased sensation), does not blanch

3rd Degree: (full thickness) Extends into Subcutaneous tissue. No blanching, leathery, minimal to no pain

Sprain/Strain Grades:

1: Mild, Little to No tearing, No Swelling

2: Moderate, Less than 1/2 of muscle torn, Bruising may occur

3: Sever:, 1/2 to Full muscle tear, Bruising

Levels of Assistance scale:

Independent: No Supervision Required

Stand by Assist: No Contact Required

Contact Guard: Contact, but no Force

Min Assist: < 25% assistance

Mod Assist: > 25% assist, <50% assist

Max Assist: 50% to 75% Assist required

Dependent: 75% to 100% Assistance

FIM Score Range:

18 to 126

18 Items Graded on 1-7 point scale

scores between 100-110 require min assist

Functional Independence Measure

Berg Score Ranges:

0 to 56

14 Items Graded on 0-4 point scale

<45 indicates greater fall risk

*Fall Risk Assessment

Tinetti POMA Score Ranges, and Cut-Points

0 to 28 Max score

14 Items Graded on 0-2 point scale

Low: 25 to 28

Mod: 19 to 14

High: 18 or less

*Fall Risk Assessment

Barthel Index:

0 to 20

10 Items graded on 0-2 point scale

*ADL independence assessment