NEUROLOGICAL ASSESSMENT FLOW SHEET

1 DATE:TIME:(Military Time)EYES 4 = SPONTANEOUSOPEN 3 = To SPEECH2 = To PAIN1 = NONEC = Eyes CLOSED by EdemaBEST 5 = ORIENTEDVERBAL 4 = CONFUSEDRESPONSE 3 = Inappropriate WORDS2 = Incomprehend. SOUNDS1 = NONET = ET / TrachBEST 6 = Obeys CommandsMOTOR 5 = LOCALIZES (Pain)RESPONSE 4 = WITHDRAWS (Pain)3 = FLEXION (Pain)2 = EXTENSION (Pain)1 = NONE GLASCOW COMA SCALE TOTAL:PUPIL SIZE: REACTION REACTION: B = BRISKN = NO REACTIONS = SLUGGISHC = EYES CLOSEDPUPIL SIZE: REACTION REACTION: ARMS NP = Normal PowerW= WeaknessNR= No ResponseLEGS NP = Normal PowerW= WeaknessNR= No ResponseREFLEXES CORNEAL: P =PRESENTGAG: A =ABSENTBABINSKI: SEIZURE ACTIVITY: BREATHING PATTERN: INTIALS:8850319 Rev. 05/05 PAGE 1 of 2 NEUROLOGICAL ASSESSMENT Flow Sheet_NURSING RIGHT LEFT ( See Reverse ) ( See Reverse )PART OF THE MEDICAL RECORDNEUROLOGICALASSESSMENTFLOW SHEETPATIENT IDENTIFICATION12 3 4 5 678 EXTREMITIES: Record RIGHT ("R") and LEFT ("L") if there is a difference between the two sides.

2 SEIZURE ACTIVITY No loss of consciousness; may involve motor, sensory and / or autonomic , May be preceded by an aura. At onset of seizure, there will be a consciousness LOBE Ends with a post-ictal -or- AKINETIC Sudden loss of body tone -or- body MAL Sudden onset and cessation -or- loss of responsiveness; no post-ictal symptoms. Or tonic-clonic seizures. Pre-ictal symptoms may involve focal seizure. Loss MAL consciousness at onset of seizure with increased muscle tone ( rigid flexed and rigid extended postures ). Bilateral rhythmic jerks follow and become further apart. Post- ictal period Generalized tonic-clonic seizure lasting longer than 30 minutes -or- failure of patientEPILEPTICUS to regain consciousness between a series of seizures. BREATHING PATTERN Increased frequency of Cessation of Spasmodic respiratory effort, may be regular or - STROKES Cycles of gradually increasing tidal volume, followed by gradual decreasing tida volume.

3 TERM Responds immediately and fully to visual, auditory or tactile Drowsy, sleeps a lot, but is easily aroused and then responds to visual, auditory or tactile Can be aroused by stimuli ( not painful ); will then respond to questions or commands. Remains aroused as long as stimulus is applied. During the arousal, patient responds but may be Very hard to arouse. Looks around when stimulated. May obey commands at times. May curse or say "don't" when Purposeful movements when stimulated. Does not obey commands or answer questions. Does not talk at Decorticate: draws hands up onto chest when stimulated, but not purposely. Decerebrate: extends arms and legs, arches neck and internally rotates hands and arms when stimulated. Unresponsive: no response to any Rev. 05/05 PAGE 2 of 2 NEUROLOGICAL ASSESSMENT Flow Sheet_NURSINGDESCRIPTIVE TERMS FOR LEVEL OF CONSCIOUSNESSPART OF THE MEDICAL RECORDINITIALSIGNATUREINITIALSIGNATURE