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NEUROLOGICAL
| M.R.N. |
| SURNAME ………………………………………………………… � D.0.6………………………………. . SEX OTHER NAMES ……………………………………………………………………………… |
AssignmentTutorOnline
OBSERVIONS
FACILIT: ____ _ __
General Instructions
| C 1 ( f C E 0 0 3 0 C u C a ·a :c Verbal Response Confused 4 Inappropriate words 3 Record ‘D’ if dysphaslc Incomprehensible sounds 2 ‘T’ if intubated No verbal response 1 Best Obeys commands 6 Motor Response Localising pain 5 Withdrawal from pain 4 See reverse for Abnormal flexion to pain 3 to guidance determine on how best Abnormal extension to pain 2 motor response No motor response 1 Total Score R Record reaction to light as Size (mm) ‘+’ if normal Reaction ‘S’ if sluggish Reaction L ‘-‘ ‘C’ifIfnone eye closed by swelling Size (mm) |
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| Date Time |
24/3 | 25/3 | 03 00 |
04 00 |
05 00 |
06 00 |
07 00 |
| 23 25 |
24 00 00 30 01 00 |
02 00 |
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| 4 4 + + |
4 4 4 4 + + + + |
4 4 4 4 4 4 + + + + + + |
5+4+ 5+4+ |
4+4+ |
C
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C
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1. Each time a set of neurological observations are recorded; a complete set of vital signs (RR,
Sp0 , BP HR, T°, Consciousness) should be completed and recorded on the ADDS
observation chart
Best Eyes open spontaneously 4
Eye
Response Eye opening to verbal stimuli 3
Record ‘C’ if no response Eye opening to pain 2
possibly due to bilateral
periorbital swelling No eye opening 1
Best Orientated 5
1 2 3 4 5 6 7
Pupil scale
(mm) • • • • • e •
Normal power
Mild weakness
Severe weakness
Arms
Spastic flexion
Extension
Record findings for None
RIGHT (‘R’) and LEFT (‘L’)
separately if different Normal power
Mild weakness
Legs Severe weakness
Extension
I None
(Adopted from Wiese, M, UHL, Patient Safety First, WHS, UK)
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