Modified Aldrete Scoring System
(PACU Recovery Assessment)
Modified Aldrete Scoring System
It is a commonly used scale for determining when
people can be safely discharged from the
post-anesthesia care unit (PACU) to either the
postsurgical ward or to the second stage (Phase II)
recovery area.
3 Categories of Post Surgical Recovery:
A. Phase 1: Early recovery
Immediately after surgery which
takes place in a critical care unit, where the patient
will stay until they have sufficiently recovered
respiration, level of consciousness, blood pressure
and activity.
B. Phase II: Intermediate recovery
Step down unit in which the patient
is given food and drink, and will be readied to go
home
C. Phase III: Late recovery
Take place at home for the
ambulatory surgical patient, and will conclude when
the person has completely recovered from their
surgical procedure
The Modified Aldrete Scoring System is a tool
utilized in the Phase I in the early recovery phase
after surgery to determine the safe discharge from
the post-anesthesia care unit (PACU).
The criteria includes assessment of patient's
consciousness, activity, respiration, blood pressure
and oxygen saturation to determine recovery. A
score of 0–2 is given for each of the five categories,
for a maximum score of 10.
A score of 8-10 is considered adequate to
discharge a patient from Phase I of post anesthesia
care.
How often is Aldrete Scoring Done?
General rule:
3 points below baseline: Every 5 minutes with
constant one-on-one monitoring.
2 points below baseline: Every 15 minutes with
constant monitoring of vital signs.
1 point below baseline: Every 15-30 minutes with
vital signs depending upon patient condition.
ASSESSMENT OF THE NEUROLOGIC SYSTEM
Assessing Consciousness and Cognition
1. Mental status
a. Observe for the patient’s appearance and
behavior, noting dress, grooming, and personal
hygiene.
b. Observe for posture, gestures,
movements, and facial expressions.
c. Assess for orientation to time, place, and
person assist in evaluating mental status
2. Intellectual Function
a. Assess patient’s intellectual level
b. Allow patient to make judgments
about situations and similarities
3. Thought Content
a. Assess patient for spontaneity of thought.
Is it natural, clear, relevant, and
coherent?
b. Assess for presence of fixed ideas or illusions
c. Assess for perception of death, morbid
events, hallucination and paranoid ideation needs
further evaluation
4. Emotional Status
a. Assess for presence of mood fluctuation or
swings
b. Check for patient’s affect
c. Assess if affect is appropriate to words and
thought content
d. Check for consistency of verbal communications
with nonverbal cues?

5. Language Ability:
A person with normal neurologic function can
understand and communicate in spoken and written
language
a. Assess for the ability to answer questions
appropriately
b. Identify ability to read and explain its meaning
Assess for ability to write or copy a simple figure
C. Assess for aphasia (language function
deficiency) Glasgow Coma Scale
It is a technique of objectifying a client’s level of
The Speech Centers are as follows: responses. The client’s best response in each area
is given a numerical value and the three values is
Broca’s Area – in the left frontal lobe. This is the totaled for a score ranging from 3 - 15.
motor speech center. This enables a person to
speak and make gestures.
Wernicke’s area – in the temporal lobes. This is the EYE OPENING ABILITY Score
auditory speech center. This enables a person to
interpret sounds or language. Spontaneous 4
Visual speech center in the occipital lobe. This To voice / speech 3
enables a person to read or interpret symbols. To pain 2
None 1
Types of Aphasia:
a. Auditory-receptive
BEST MOTOR RESPONSE Score
Involved Brain Area: Temporal lobe
b. Visual-receptive
Involved Brain Area: Parietal-occipital area Obeys commands 6
Alexia – inability to read Localizes to pain 5
c. Broca's Aphasia –expressive; difficulty in Flexor withdrawal (decorticate 4
forming sentences posturing)
Involved Brain Area : Frontal regions of the left Abnormal flexion (decerebrate 3
hemisphere posturing)
d. Global Aphasia- receptive; difficulty in Extension 2
understanding and forming words
Flaccid 1
Involved Brain Area: Front and back regions of the
BEST VERBAL RESPONSE
left hemisphere

Level of Consciousness Oriented 5

Consciousness is the patient’s wakefulness and Confused conversation 4
ability to respond to environment Inappropriate words 3
It is the most sensitive indicator of neurologic Incomprehensible sounds 2
function
Observe for alertness and ability to follow Finger tip pressure- Peripheral pain stimuli
commands
Observe for eye opening, verbal response
and motor response to stimuli.
Trapezius Squeeze

Suborbital Notch Pressure

Examining the cranial nerves

MOTOR SYSTEM
Glasgow Coma Scale
Analysis of Scores: A. Motor ability
A score of 15 indicates client is awake and
oriented. a. Assessment of muscle size, tone, strength,
A score of 7 to 4 is considered coma. coordination and balance
The lowest score is 3,client is considered in deep
coma b. Patient is told to walk across the room while the
examiner observes posture and gait
Generally, brain injury is classified as:
Severe, GCS < 8–9
Moderate, GCS 8 or 9–12 (controversial)[9]
Minor, GCS ≥ 13.

https://www.glasgowcomascale.org/#video

Decorticate posture is an abnormal posturing in

which a person is stiff with bent arms, clenched
fists, and legs held out straight. The arms are bent
in toward the body and the wrists and fingers are
bent and held on the chest.

c. Inspection of the muscles, palpation for size and

symmetry; palpation of group of muscles at rest
and during passive movement to assess muscle
tone

Decerebrate posture is an abnormal body posture
that involves the arms and legs being held straight
out, the toes being pointed downward, and the
head and neck being arched backward. The
muscles are tightened and held rigidly.
d. Check for muscle atrophy and involuntary
movement ( eg. ticks, tremors)
B. Muscle strength:
a. Assess for the ability to flex or extend the
extremities against resistance.
5-point scale to rate muscle strength:
5= full power of contraction against gravity and
resistance
4= fair but not full strength against gravity;
moderate amount of resistance or slight weakness
3= sufficient strength to overcome the force of
gravity or moderate weakness
2= able to move but not to overcome the force of
gravity or severe weakness
1= minimal contractile power; no movement is
noted
Tests to assess the Sensory Function:
A. Tactile Stimulation
Touch: is a perception resulting from the activation
of neural receptors in the skin, including hair
follicles, tongue, throat, and mucosa. A variety of
pressure receptors respond to variations in
pressure (firm, brushing, sustained, etc.).

B. Balance and Coordination

The cerebellum and basal ganglia influence the
motor system through balance control and
coordination

a. Rapid, alternating movements

b. Point-to-point testing B. Pain or nociception (physiological pain): Signals
c. Test for the coordination of the lower extremities. nerve and other tissue damage.
Each leg is should be assessed.

C. Temperature sensation test

d. Romberg test to screening for balance
Two test tubes with stoppers are required for this
examination; one should be filled with the cold
water (between 5°C to 10°C) and warm water(
40°C to 45°C). The test tubes are randomly placed
in contact with the skin area to be tested. All skin
surfaces should be tested. The patient is asked to
respond hot and cold after each stimulus
application.

B. SENSORY SYSTEM

* Examiner should be familiar with the dermatomes

which represent the distribution of peripheral
nerves that arise from the spinal cord
D. Body awareness or Proprioception: Provides the
* Involves examination of the ANS to test for tactile parietal cortex of the brain with information on the
sensation, superficial pain, temperature, vibration relative positions of the parts of the body.
and proprioception.

Tests to assess the Sensory Function:

Tactile Stimulation
Pain and temperature sensation test
Vibration and Proprioception tests
Special Senses
Sight: ability of the eyes to focus and detect
images of visible light on photoreceptors in the
retina that generate electrical nerve impulses for
varying colors, hues, and brightness.
Hearing: the sense of sound perception. The
vibrations are mechanically conducted from the
eardrum through a series of tiny bones to hair-like
fibers in the inner ear that detect the mechanical
motion of the fibers.
Whisper test
Tuning fork Test
Taste: refers to the ability to detect substances
such as food, certain minerals, poisons, etc. The
sense of taste is often confused with the concept of
flavor, which is a combination of taste and smell
perception. Flavor depends on odor, texture, and
temperature as well as on taste.
Smell: the olfactory system is the sensory system
used for the sense of smell (olfaction). This sense
is mediated by specialized sensory cells of the
nasal cavity.
Ankle jerks are normally absent in older people
A normal reflex will cause the foot to plantar flex.
B. Biceps reflex test
Examines the function of the C5 reflex arc and the
C6 reflex arc (musculocutaneous nerves)
Elicited by striking the biceps tendon over a slightly
flexed elbow.
Normal response: flexion at the elbow and
contraction of the biceps
C. Triceps reflex-
Assessment of the C7, C8 - Radial Nerve
elicited by patient’s arm flexed at elbow and
positioned in front of the chest.
The normal reflex will cause the lower arm to
extend at the elbow and swing away from the body.

Assessment of Higher Cortical Sensory Ability

1. Two-point discrimination Test

used to assess if the patient is able to identify two
close points on a small area of skin, and how fine
the ability to discriminate this are.
2. Tactile identification/ Shape texture identification
Asses for tactile agnosia or astereognosis
Stereognosis test involves using your tactile
D. Brachioradialis reflex-
discrimination and touch perception skills to identify
Assessment of the C5, C6 - Radial Nerve
and recognize an object or group of objects with
assessed with the patient’s forearm resting on the
vision occluded;
lap or across the abdomen;
Fingers essentially “read” between the objects of
A normal reflex will cause the lower arm to flex at
different textures, temperatures, sizes, shapes, and
the elbow and the hand to supinate (turn palm
weights and send information to the brain to figure
upward).
out the object

E. Patellar reflex-
C. Reflex Examination Assessment of L3, L4 -Femoral Nerve
Deep tendon reflexes Elicited by striking the patellar tendon just below
A. Achilles reflex the patella in a sitting or lying position;
Assessment of the S1, S2 - Sciatic Nerve Normal responses: Contraction of the quadriceps
Reflexes should be symmetrically equivalent and knee extension
G. Clonus
Reflexes are very hyperactive
- if the foot is abruptly dorsiflexed, it may continue
to “beat” 2-3 times before it settles into a position of
rest- persist with the presence of a CNS disease

Types:
1. Unsustained- with normal but with hyperactive
reflexes= NOT pathologic
2. Sustained- always indicates the presence of
CNS disease.

Superficial reflexes:
A. Corneal- with the use of a clean wisp of cotton
touching the outer corner of each eye;
Normal reaction: Blinks
B. Gag- by gently touching the back of the pharynx
with a cotton-tipped applicator one side at a time;
Normal reaction: “gag” with stimulation
C. Plantar – elicited through stroking the
sole of the foot with a tongue blade or the handle of
a reflex hammer.
Normal reaction: Stimulation causes toe flexion

Pathologic reflexes seen in the presence of

neurologic disease

A. Babinski reflex- pathologic reflex indicative of

CNS disease affecting the corticospinal tract; lateral
aspect of the sole of the foot is stroked, toes fan out
and draw back