Rising Intracranial Pressure
A 22-year-old client fell from a ladder and struck the head. The client was initially awake and talking but has become increasingly difficult to arouse over the last hour.
Recognize cues
Vital signs: BP 168/62, HR 52, RR 10 and irregular, SpO2 94%, temperature 37.0 C. The client opens the eyes only to pain, the right pupil is 5 mm and sluggish, and the left is 3 mm and brisk. Glasgow Coma Scale has fallen from 14 to 9.
Which finding requires the most immediate follow-up?
Take action
The provider is notified and orders the head of the bed elevated 30 degrees, IV mannitol, an emergent head CT, and preparation for possible surgical decompression.
Which two actions should the nurse take first?
Evaluate outcomes
After surgical evacuation of the hematoma the client opens the eyes to voice and follows commands, pupils are 3 mm and equally reactive. BP 128/76, HR 78, RR 16.
Which finding best indicates the treatment is working?
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