Published Nov 3, 2008
NurseyPoo7
275 Posts
Pt in her 80s. Found "unresponsive" at home. Aphasic. Left side flaccid.
Dx: Massive CVA of nearly the entire right brain.
Assessment:
R pupil - fixed & dilated
L pupil - sluggish, 4mm
Does not respond to her name being called
Winces to trapezius pinch & sternal rub.
Will not grasp with either hand on command. (Had previously had a weak grasp on the right days earlier)
Will move feet slightly if you touch the soles of her feet.
Requires frequent suctioning for oral secretions - occassionally appears to have a gag reflex, and occassionally seems to "clear" her throat after suctioning.
I was to call her unresponsive but she does respond to pain/procedures somewhat. Would she be considered stuporous instead?
PICNICRN, BSN, RN
465 Posts
I would call her responsive to painful stimuli or something along that line. I think a GCS would be more appropriate though. That gives people a better idea.