NVS RD patient is

A. GCS and Reaction Level scale experiencing

a. Checks the doctors order for weakness in either or
Neuro vital signs both sides of the
i. To ensure that the body.
order was made by ii. Leg movement kay
the doctor. yung raise and legs
b. Observes universal isa isa tas yung
precautions (proper hand resistance.
washing) iii. Strong (S), Moderate
i. To deter the spread of (M), Weak (W),
microorganisms Absent (A)
c. Prepares the equipment D. Level of consciousness
needed a. Notes the patient’s eye
i. To save time and opening in response to the
energy. instructions given by the
B. Mental status nurse/student nurse.
a. Ask the patient’s name, date, i. The moment you
time, and other questions to enter the room,
test awareness. observe the patient’s
i. The patient’s eye movement
response to these immediately to score
questions can the eye response.
determine if he/she is ii. 4 (Spontaneous), if
having problems with the patient has their
neurological status. eyes open and has
C. Pupil Motor Response movements when you
a. Gives proper instructions and enter the room.
performs the correct test of iii. 3 (Sound), If the
pupil size and reaction. patient opens their
i. The normal pupil eyes after you speak.
sizes are 2-4, and 4-8 iv. 2 (Pain), If the patient
when in the dark. opens their eyes after
Pupils should you put pressure on
constrict immediately their nail bed.
when light is directly v. 1 (No response)
pointed at it. b. Observes the patient’s verbal
ii. Brisk (B) - ideal result response to all questions
iii. Fixed (F) given by the nurse/student
iv. Sluggish (S) nurse.
b. Gives proper instructions and i. Asking the patient for
performs the correct test for their name, date
the upper extremity (hand today will help us
grip). score the verbal
i. Instructions may help response of the
patient to cooperate patient.
ii. The hand grip test will ii. 5 (oriented), if the
help us determine if patient answered all
the patient is the questions
experiencing correctly.
weakness in either or iii. 4 (confused), if the
both sides of the patient answered all
body. or some of the
c. Gives the proper instructions questions incorrectly.
to raise or move the lower iv. 3 (Inappropriate), if
extremity (leg movement). the patient’s answer
i. The leg movement is not connected to
test will help us the question.
determine if the
 v. 2 (Incomprehensive), c. Records the data correctly
if the patient just d. Interprets the result of the
groans or moans. neuro vital sign
c. Performs different tests to i. To identify the
obtain motor response patient's neurological
i. Give the patient status.
instructions, to see if ii. The lower the score
they can obey the better!
command (1 - Obeys e. Answers questions related to
Command), If they the procedure.
are unconscious,
perform trapezius
pinch or supraorbital
notch pressure and
observe and rate the
patient's response.
ii. 5 (Localizes pain), if
the patient is able to
identify where the
pain is, and removes
it with their own hand.
iii. 4 (Withdraws from
pain)
iv. 3 (Abnormal flexion) ,
decorticate.
v. 2 (Abnormal
extension),
decerebrate.
vi. 1 (no response)
d. Observes the patient’s motor
response to all instructions
given by the nurse/student
nurse.
i. Observe in order to
get a score.
e. Writes down the score for
each test according to the
patient’s response and add
the total score.
i. For documentation
f. Interprets result of the motor
response based on the GCS
chart.
i. To determine the
neurological status of
the patient.
ii. 15 - normal
iii. >13 - minor brain
injury
iv. 9-12 - moderate brain
injury
v. <8- severe brain
injury.
E. Reaction Level Scale
a. Gives the proper scale of the
mental response of the
patient.
b. Obtains the vital signs
correctly.