CLC monitoring HELP!

[xyrhana]

Hey guys!

I'm a fresh grad and I just got posted to a neurosurg ward. Since I have learnt how to perform CLC on patients, I am expected to know how to do it. Indeed, I do know how to do this but for many of my stroke patients, they are impossible to arouse from their sleep. Even if I do apply pressure/pain, the patients only react in terms of facial expression. How do I even classify that reaction? Naturally, if they are not aroused, I cannot continue with my assessment. Does anyone face the same problem? If so how do you perform hourly CLC? (Our CLC consists of GCS, vital signs, pupil reaction and arm and leg motor strength). Is hourly monitoring something feasible?

[Here.I.Stand, BSN, RN]

In that case, they'd get a 2 for eye opening to pain on the GCS. For motor response if they are not following commands nor moving spontaneously, we do the pinch test on each extremity to see are they localizing, withdrawing, posturing, or no response; then on the GCS, they get the points for their best response. So if they can follow commands on their left side but are completely paralyzed on the left, they would get 6 points for motor response.

I've never heard of doing hourly neuro checks on the floor. When I worked the floor we did neuro checks at most q 4 hrs. Progressive care/stepdown can do q 2 hrs, but if their status is such that they truly need an hourly neuro check they should be in the ICU.

[xyrhana]

Thank you for your respond. I really need to feedback to my supervisor that these orders from the doctor are impossible because they do order hourly CLC on the floor where one staff nurse has 6 patients to attend to. I'm from Singapore by the way and i believe as a result of this impossible task, nurses aren't charting accurately.