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Level of Consciousness
Motor Strength
Motor Response
Documentation
Miscellaneous
100
Arouses easily from sleep with quick, normal, cognition
What is Awake
100
Full strength against resistance
What is #5
100
Trapezius squeeze, Supraorbital notch pressure, bicep tendon pinch
What are central pain stimuli
100
GCS 15, Awake, Oriented x4, PERL, follows commands in all 4 extremities, full strength against resistance on a non -neuro patient
What is WDL on neuro section of the head to toe assessment
100
Altered Cerebral Perfusion Plan of Care
What is what plan of care should be initiated on all ischemic, hemmorhagic and SAH patients (or all stroke patients)
200
No eye opening to painful stimulus
What is Comatose
200
Can lift body part, but provides no resistance
What is #3
200
Inner bicep, Inner thigh, nailbed pressure (last choice)
What is peripheral pain
200
This is the only exam used in Acute Care, Tele, IMU. It may also be used in ICU, ED
What is the basic neuro exam
200
VS and basic neuro exam q15 min x2; q30min x6; q1h x 16 hours
What is post TPA for ischemic stroke vital signs
300
Arouses easily but slow cognition or motor activity
What is Lethargic
300
Provides some resistance
What is #4
300
Flexes at ankles, knees, hips on the same side
What is triple flexion
300
Larry Opposed Parrallel Parking Most Mondays
What is the acronym for the basic neuro exam; LOC, Orientation, Pupils, Pronation, Motor Response, Motor Strength (also includes GCS)
300
Dysphagia screening / Water Swallow Protocol
What must be done on every single stroke pt prior to administering or documenting any PO meds or fluids
400
Drowsy, requires non-painful stimulus to open eyes
What is Obtunded
400
Flicker of voluntary motor contraction
What is #1
400
Locates stimulus and combats it
What is localizes
400
Complete the expanded neuro assessment so only the basic neuro assessment is visible on the EPIC screen
What is the acute care, Tele, IMU RN to do when receiving a pt from ICU who had been receiving the expanded neuro exam in ICU
400
This is the title of the Emmi video that must be assigned to all stroke patients prior to discharge
What is "Stroke and TIA
500
Unresponsive except when stimulated. Requires painful stimulus to open eyes
What is Stuporous
500
Can not lift body part, but can move it laterally
What is #2
500
Pulls away from pain
What is Withdraws
500
This are the MD order options for neuro exams on neuro patients
What is basic neuro exam; what is ICU expanded neuro exam
500
Five patient education points that must be documented prior to discharge on all stroke patients
What is Calling 911; Signs / Symptoms of stroke; risk factors for stroke; medications on discharge, follow up appointments