CLC Documentation Flashcards
What is the purpose of conscious level chart?
To perform neurological assessment and asses for changes in neurological status in patient.
What are the three components of glascow coma scale (GCS)?
best eye opening response, best verbal response and best motor response
What does the GCS scores mean?
Highest - 15 (Fully alert, well orientated)
Lowest - 3 (Deep coma)
13 -15: Mild head injury
9 to 12: Moderate head injury
8 or less: Severe head injury
What are the 4 responses to eye opening?
Spontaneous (4), to speech (3), to pain (2) and none (1)
What does it mean if the patient open his eye spontaneously?
Patient open his eye without external stimulus, arousal mechanisms in the brainstem are active but does not imply awareness.
What does it mean if the patient open his eye to speech?
Patient open eyes to sound of voice either spoken or shouting.
What does it mean if the patient open his eye to pain?
Patient open his eye to pain stimulus such as pain on fingertip
What does it mean to have no response?
Patient dont open eyes to any stimulus
What are the 5 responses to verbal response?
Orientated (5), confused (4), Inappropriate words (3), incomprehensible sound (2), none (1).
What does it mean for patient to be orientated?
The patient is orientated to time place and person i.e, awareness of environment and self
What does it mean for patient to be confused?
Patient is able to converse but give irrational replies
What does it mean for patient to response with inappropriate words?
Patient speak in random words and phrases that make little or no sense, i.e, articulation but no conversational exchange
What does it mean for patient to response with incomprehensible sound?
Patient responds with groans and moans without any recognisable words
What does it mean for patient to have no response?
Patient dont respond verbally
What are the 6 components of motor response?
Obey command (6), localised pain (5), flexion to pain (4), abnormal flexion (3), extension to pain (2) & none (1).
What does it mean for patient to obey command?
Patient is able to follow simple command eg grip and release hand; lift up limbs
What does it mean for patient to localise pain
Patient is able to locate the painful stimulus and attempt to remove the source (move arm across midline of body or to clavicle)
What does it mean when patient have flexion to pain
Patient is able to flex limb to pain (flex arm but cannot remove the pain source)
What does it mean when patient have abnormal flexion
Patient arm are adducted and flexed, and the fingers and wrist are flexed on chest
What does it mean when patient have extension to pain
Patient’s arms are adducted and extended with the wrists pronated and the fingers flexed.
What does it mean when patient have no response
Patient has no motor response to pain on any limb
Where to apply pain stimulus to test for motor response?
Squeeze patient trapeziu muscle to test for cranial nerve XI
How to apply pain stimulus?
It should be given with gradual intensitive to elicit response but no more than 10 seconds
Another word for abnormal flexion
Decorticate (leison of the frontal lobe, internal capsule and cerebral peduncles)
