Question

Mr Reynold had undergone craniotomy and he is on 2nd post op day. You are there to take over the client from the staff of previous shift. Answer the following question based on the scenario.

On assessing the level of consciousness of Mr Reynold, you got a score of E2M3V1, which is entirely different from the previous reading (E4M4V3).
1. Mention your interpretation.

2. Describe how you would respond in this situation as an enrolled nurse (in 40-50 words).

3. Mention the tool used for assessing his level of consciousness

Answer 1

Eye opening scores

• 4: Spontaneously

• 3: To verbal command

• 2: To pain

• 1: No response

Best motor response scores

• 6: Obeys command

• 5: Localizes pain

• 4: Flexion withdrawal

• 3: Flexion abnormal (decorticate)

• 2: Extension (decerebrate)

• 1: No response

Best verbal response scores

• 5: Oriented and converses

• 4: Disoriented and converses

• 3: Inappropriate words; cries

• 2: Incomprehensible sounds

• 1: No response

On assessing the level of consciousness of Mr Reynold,got a score of E2M3V1, it means eyes opened to pain, flexion abnormal when assessed for motor response and no verbal response

now he has (E4M4V3). it means his eyes opened spontaneously, flexion withdrawl when assessed for motor response and he spoke inappropriate words and sometimes he cries.

Adult glasgow coma scale used for assessing his level of consciousness.

GCS score is 11. moderate head injuries were of the GCS score between 9-12.

Nurse has to continuously monitor the patient.

She has to assess for physical effects, cognitive effects and behavioural problems of patients