You are the nurse on nightshift and Maisie is one of your patients who is on 4 hourly observations. It’s time for her 2am observations. On completing her chart you notice that her GCS has changed since her last set of observations which were taken at 10pm.
What should you do?
Reassess in 4 hours – No, you must reassess Maisie immediately as her stroke may have extended.
Reassess Maisie immediately – Yes, this is correct.
Page last reviewed: 03 Mar 2021
