Head/Spine Injury |
Score: ____ out of ____ possible points (Max of 12) |
1. Assesses level of consciousness |
0 = Not completed 1 = Delayed or incorrect performance 2 = Correctly performed appropriate timing [GCS] |
2. Pupil assessment |
0 = Not performed 2 = Performed |
3. Assesses for neurologic deficit |
0 = Not performed 1 = Partial assessment 2 = Performed |
4. Performs appropriate interventions as indicated for traumatic brain injury (i.e., elevate the head of the bed or reverse Trendelenburg, maintain appropriate blood pressure, avoid hypoxemia) |
0 = Indicated, not completed 1 = Indicated, delayed or incorrect performance 2 = Indicated, correctly performed, appropriate timing |
5. Maintains spinal precautions |
0 = Indicated, not completed 1 = Indicated, delayed or incorrect performance 2 = Indicated, correctly performed appropriate timing |
6. Hypertonic Saline and/or Mannitol administration |
0 = Indicated, not completed 1 = Indicated, delayed or incorrect administration 2 = Indicated, correctly administered, appropriate timing |
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