Neurological Flow Sheet

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Neurological Flow Sheet

  1. 1. Neurological Flow Sheet Vital Signs and Neuro Checks: - q 15 mins. X ( 1) hour - q 30 mins. X ( 1) hour - q 1 hour X ( 4) hours, then - q 4 hours X (24)hours (Progress along this time schedule ONLY if signs are stable) Date: Time: Level of Conciousness: Movement: Hand Grasps: Pupil Size: Rt. Pupil Size: Lt. Pupil Reaction: Rt. Pupil Reaction: Lt. Speech: B/P: Pulse: Respiration: Temperature: See Nurse's Notes: * Initials: KEY: Level of Conciousness Movement Pupil Size Chart 1. Fully Concious - awake, aware, oriented 1. All 4 extremities 2. Lethargic - responds slowly to verbal stimuli 2. Arms only 3. Obtund - very drowsy, responds to touch stimuli 3. R arm only 4. Stupor - responds only to painful stimuli 4. L arm only 1 mm 2 mm 3 mm 5. Coma - absent response to stimuli 5. R leg only 6. L leg only 7. No movement/unusual movement Hand Grasp Speech 4 mm 5 mm 6 mm Pupil Reaction 1. Equal and strong 1. Clear 2. R weaknesss 2. Slurred 1. Brisk 3. L weakness 3. Rambling 2. Sluggish 4. None 4. Aphasic 3. Fixed 7 mm 8 mm 9 mm Notify MD IMMEDIATELY of signs and symptoms of Intracranial Pressure!!! Resident Name: Room # Physician: Medical Rec. # Automated Laser Forms by Data Systems ,Inc. (914) 591-1800 Neuro.FRP MSB 1/97

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