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SKILL 35 EVD: Client Assessment

PROCEDURE DOCUMENTATION
1. Monitor neurological status every 4 hours or as ordered. 1. Assessment findings.
2. Include the following in the assessment:
a. Level of consciousness.
b. Bilateral grip strength.
c. Pupil size and response to light.
d. Vital signs.
e. Presence or absence of headache, nuchal rigidity,
vomiting, double vision, slurred speech, dizziness,
and ataxia.
f. Blood or clear drainage from nose or ears.
g. Presence or absence of seizures.
3. Assess insertion site and skin condition at least once a
shift. Assess for redness and drainage.

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