Acute Caremiddle twist
A 31-year-old man is intubated in the emergency department after falling from a roof and is transferred to the intensive care unit. Sedation has been withheld for twenty minutes so that he can be assessed. He opens his eyes only when firm pressure is applied over the trapezius, and when this is done he reaches across the midline towards your hand. He does not respond to any request. He remains orally intubated with a cuffed tube. The nurse asks what to enter on the neurological observation chart. Which one of the following entries is correct?