CHAPTER 5 Nervous System^215
NURSING INTERVENTION
- Avoid discussing the patient’s condition in the presence of the patient—
remember the patient can still hear you even though he or she is not con-
scious, and may recall the conversations after they regain consciousness. - Monitor vital signs for stability—increased blood pressure with widening
pulse pressure and slow pulse, suggestive of increased intracranial pressure. - Monitor neurologic status for changes—typically use Glasgow Coma Scale
or similar tool to grade response to stimuli (highest score 15):- Eye-opening response spontaneous^4
to sound 3
to pain 2
none 1 - Motor responses obeys commands^6
localizes pain 5
withdrawal (normal) 4
abnormal flexion 3
extension 2
none 1 - Verbal responses oriented^5
confused conversation 4
inappropriate words 3
incomprehensible sounds 2
none 1
- Eye-opening response spontaneous^4
- Monitor for signs of intracranial pressure—report changes.
- Check for signs of infection at wound site in post-operative patients.
- Monitor signs for diabetes insipidus—increased risk due to injury to the pitu-
itary gland. - Monitor intake and output.
- Monitor urine specific gravity, serum, and urine osmolarity.
- Collaborate with dietician for appropriate diet, if any swallowing or oral sen-
sory concerns. - Seizure precautions per institution policy.
- Explain to the patient and family:
- Any dietary restrictions.
- Any activity restrictions.
- Medication actions, side effects, interactions.