(b) Localizes pain: M5. Can the patient localize the pain that he is
feeling? If you elicit a pain response by pinching of squeezing the right side, watch for
the patient to reach across with the opposite arms to check for cross body localization.
(c) Withdraws to pain: M4. This indicates a correct pain response.
The body should withdraw away from the pain and not towards it.
(d) Flexion (decorticate posturing): M3. This is an abnormal posturing
usually caused by severe brain trauma. The body curls into a protective posture by
flexing the arms into the chest.
(e) Extension (decerebate posturing): M2. In this form of posturing,
the body is abnormally extended. The arms and legs may be extended and very rigid or
difficult to move.
c. PEARRL. Use the guide PEARRL when assessing the pupillary response of
the patient's eyes.
P: Pupils. Are they both present? What is their general condition?
(2) E: Equal. Are both pupils the same size? Unequal pupils can indicate a
head injury causing pressure on the optic nerve. There is a small percent of the
population that has unequal pupils normally, so a good patient history is critical.
(4) R: Round.
R: Regular in size.
(6) L: React to light. Both eyes should be assessed twice for reaction to
light. The first time the light is shined in the right eye, for example, you should watch
the right eye for reaction, the second time the left eye should be watched to ensure
sympathetic eye movement is present. (both eyes are doing the same thing at the same
d. Vital Signs.
(1) The first set of vital signs establishes an important initial measurement of
the patient's condition and serves as a key baseline.
Monitor vital signs for any changes from initial findings throughout care.