Possibly evidenced by
Altered LOC; memory loss
Changes in motor or sensory responses; restlessness
Sensory, language, intellectual, and emotional deficits
Changes in vital signs
Desired Outcomes/Evaluation Criteria—Client Will
Maintain usual or improved LOC, cognition, and motor and sensory function.
Demonstrate stable vital signs and absence of signs of increased ICP.
Display no further deterioration or recurrence of deficits.
Nursing intervention with rationale:
1. Determine factors related to individual situation, cause for coma, decreased cerebral perfusion, and potential for 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,
which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. If the stroke is evolving, client can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is “completed,” the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence.
2. Monitor and document neurological status frequently and compare with baseline.
Rationale: Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. May also reveal TIA, which may resolve with no further symptoms or may precede thrombotic CVA.
3. Monitor vital signs noting: Hypertension or hypotension; compare blood pressure (BP) readings in both arms
Rationale: Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor.
Hypotension may follow stroke because of circulatory collapse.
4. Document changes in vision, such as reports of blurred vision and alterations in visual field or depth perception.
Rationale: Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.
5. Assess higher functions, including speech, if client is alert.
Rationale: Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate increased ICP.
6. Position with head slightly elevated and in neutral position.
Rationale: Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation and perfusion.
7. Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures.
Rationale: Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding, in the case of hemorrhagic stroke.
8. Prevent straining at stool or holding breath.
Rationale: Valsalva’s maneuver increases ICP and potentiates risk of bleeding.
9. Assess for nuchal rigidity, twitching, increased restlessness, irritability, and onset of seizure activity.
Rationale: Indicative of meningeal irritation, especially in hemorrhagic disorders. Seizures may reflect increased ICP or reflect location and severity of cerebral injury, requiring further
evaluation and intervention.
10. Administer supplemental oxygen, as indicated.
Rationale: Reduces hypoxemia.