response to injury, metabolic alterations, drug or alcohol overdose), decreased systemic BP or hypoxia (hypovolemia, cardiac dysrhythmias)
Possibly evidenced by
Altered LOC, memory loss
Changes in motor or sensory responses, restlessness
Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will
Maintain usual or improved LOC, cognition, and motor or sensory function.
Demonstrate stable vital signs and absence of signs of increased ICP.
Nursing intervention with rationale:
1. Determine factors related to individual situation, cause for coma or decreased cerebral perfusion, and potential for increased ICP.
Rationale: Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity,
requiring the client be transferred to critical care for monitoring of ICP or surgical intervention.
2. Monitor and document neurological status frequently and compare with baseline: GCS during first 48 hours
Rationale: GCS assesses trends and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CN) damage. Note: The Rancho Los Amigos Scale (or Rancho Levels) may also be used. These levels do not require cooperation from the client and are based on client’s response to environmental stimuli and a range of behavioral responses, including no response, confusedagitated, and purposeful-appropriate.
3. Evaluate eye opening—spontaneous (awake), opens only to painful stimuli, keeps eyes closed (coma)
Rationale: Determines arousal ability and LOC.
4. Assess verbal response; note whether client is alert, oriented to person, place, and time, or is confused, uses inappropriate words and phrases that make little sense
Rationale: Measures appropriateness of speech and content of consciousness. If minimal damage has occurred in the cerebral cortex, client may be aroused by verbal stimuli but may appear drowsy or uncooperative. More extensive damage to the cerebral cortex may be displayed by slow response to commands, lapsing into sleep when not stimulated, disorientation,
and stupor. Damage to midbrain, pons, and medulla is manifested by lack of appropriate responses to stimuli.
5. Assess motor response to simple commands, noting purposeful (obeys command, attempts to push stimulus away) and nonpurposeful (posturing) movement. Note limb movement and document right and left sides separately.
Rationale: Measures overall awareness and ability to respond to external stimuli and best indicates state of consciousness in the client whose eyes are closed because of trauma or who is
aphasic. Consciousness and involuntary movement are integrated if client can both grasp and release the tester’s hand or hold up two fingers on command. Purposeful movement can include grimacing or withdrawing from painful stimuli or movements that the client desires, such as sitting up. Other movements (posturing and abnormal flexion of extremities) usually indicate diffuse cortical damage. Absence of spontaneous movement on one side of the body indicates damage to the motor tracts in the opposite cerebral hemisphere.
6. Monitor vital signs: BP, noting onset of and continuing systolic hypertension and widening pulse pressure; observe for hypotension in multiple trauma client
Rationale: Normally, autoregulation maintains constant cerebral blood flow despite fluctuations in systemic BP. Loss of autoregulation may follow local or diffuse cerebrovascular damage.
Increasing systolic BP accompanied by decreasing diastolic BP (widening pulse pressure) is an ominous sign of increased ICP when accompanied by decreased LOC. Hypovolemia or hypotension associated with multiple trauma may also result in cerebral ischemia and damage.
7. Heart rate and rhythm, noting bradycardia, alternating bradycardia and tachycardia, and other dysrhythmias
Rationale: Changes in rate (most often bradycardia) and dysrhythmias may develop without impacting hemodynamic stability. However, dysrhythmias can reflect brainstem pressure or injury in the absence of underlying cardiac disease. Tachycardia can reflect hydration status, fever or hypermetabolic state, and sympathetic storming.
8. Respirations, noting patterns and rhythm, including periods of apnea after hyperventilation and Cheyne-Stokes respiration
Rationale: Irregularities can suggest location of cerebral insult, increasing ICP, and need for further intervention, including possible respiratory support.
9. Evaluate pupils, noting size, shape, equality, and light reactivity.
Rationale: Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact. Pupil size and equality is determined by balance
between parasympathetic and sympathetic innervation. Response to light reflects combined function of optic (II) and oculomotor (III) cranial nerves.
10. Assess position and movement of eyes, noting whether in midposition or deviated to side or downward. Note loss of doll’s eyes or oculocephalic reflex.
Rationale: Position and movement of eyes help localize area of brain involvement. An early sign of increased ICP is impaired abduction of eyes, indicating pressure or injury to the fifth
cranial nerve. Loss of doll’s eyes indicates deterioration in brainstem function and poor prognosis.