2.
Assess the patient’s LOC and orientation by
response to verbal, tactile, and pain stimuli.
The tool we use to assess the level of
consciousness and orientation is the Glasgow
Coma Scale (GCS). The GCS assessment uses three
categories that pertain to different areas of a
person’s conscious state, they are; eyes opening
response, verbal response, and motor response.
Each unit is given a range of numbers that
correlate with definable levels in consciousness
which are then collated to give a score between
3, indicates deep unconscious to 15, indicates
normal conscious level. The best response is
recorded for each category.
Prior to the assessment, it is essential to check
first for factors that may interfere with
communication, ability to respond and other
injuries.
Glasgow Coma Scale (GCS)
Eye Opening Response:
In this component, a score of perfect 4 is given if
the patient’s eyes open spontaneously with no
prompting from the one who is assessing upon
the initial approach.
A score of 3 will be given when patient’s eyes do
not open spontaneously but will do only upon
initiation of a verbal stimulus.
A score of two, when patient’s eyes do not open
spontaneously or with verbal stimulation, but
they do open to painful stimulation.
& A score of 1 will be given if there is no eye
opening to any stimuli.
Verbal Response:
Next component of the GCS is the verbal
response.
A score of perfect 5 is given if the patient answers
questions related to being oriented to person,
place, & time.
Give a score of 4 if the patient is confused or
disoriented to any or all of time, place, and
person.
Give a score of 3 if the patient clearly articulates
words, but his/her verbal responses have no
relation to the context of the questions.
Give a score of 2 if the patient fails to articulate
words, but does utter a sound such as moaning or
groaning.
& a score of 1 if there is no verbal response to any
form of stimuli.
Motor Response:
The last component of the scale is the motor
response.
A perfect 6 will be given if the patient is able to
understand and obey commands such as “raise
your right hand”, “turn to sides”
A score of 5 is given if the patient moves a limb in
an attempt to locate and remove the source of
the applied painful stimulus.
A score of 4, if the patient withdraws the limb in
response to a painful stimulus by flexing the
elbow/knee with the limb drawn away from the
trunk.
A score of 3, if the patient flexes the limb at the
elbow in response to painful stimuli.
Accompanying this movement is shoulder
adduction, wrist flexion and the making of a fist.
Flexion to pain is usually a slow movement, with
no attempt to remove the painful stimuli.
A score of 2, if the patient extends the limb at the
elbow in response to painful stimuli. This
movement is also called decerebrate.
Accompanying this movement is adduction of the
shoulder; flexion of the wrist while the fingers
either make a fist or extend.
& lastly, give a score of 1 if there are no
movement of the limbs occurs in response to
painful stimuli.
5. Perform a postoperative drift check on
neurovascular patient
To perform a postoperative drift check,
remember to assess pain, paralysis, paresthesia,
pallor, temperature, capillary refill, pulselessness,
& swelling and increased pressure.
Assess for:  Cutaneous sinus tract drainage (CSF leaks
 Pain into the sinus tract, which then creates a
o Use numerical pain scale to pathway to drain through the skin)
evaluate the severity of the pain  Loss of sense of smell (anosmia)
the patient is feeling.  Change in hearing or ringing in the ears
 Paralysis
o Check for inability to actively move
the limb and increased pain on
passive movement that is not
relieved in extension.
 Paresthesia
o Assess for feelings of tingling, pins
and needles, & numbness.
 Pallor
o Assess appearance of extremities if
cold and pale.
 Temperature
o Assess coolness of the limb distal
to injury.
 Capillary refill
o Assess through checking one finger
of choice, pressing it down and
time the return of blood flow in
the nails. Normal Value: (<2
seconds)
 Pulselessness
o Assess pulse distal to
injury/surgery
 Swelling and Increased Pressure:
o Assess skin if presents as tight and
shiny.
9. Assess any suspicious drainage (otorrhea and
rhinorrhea) for the presence of CSF

Check for common indicators of cranial CSF leak:

 Drainage from the nose (rhinorrhea)
o Ask the patient to lean forward
and observe if there is an increase
flow of nasal discharge
 Drainage from the ear (otorrhea)
o Ask the patient to tilt the head
forward or strain and observe for
increase drainage

Other ways to check for CSF leak:

 Salty or metallic taste in the mouth
 Sense of drainage down back of throat