(b) Characterized by a diminished response to environmental stimuli.
Responsiveness ranges from alert and oriented to no response to
(d) Confusion, restlessness, disorientation, and drowsiness may be
signs of an impending change.
Headache--increases in severity with coughing, sneezing, or straining at
(a) Edema and pressure of both the optic nerve and the oculomotor
nerve at the point at which they enter the globe is caused by venous congestion
resulting from increased intracranial pressure.
(b) Pupil on the affected side may be nonreactive.
Pupils may be unequal, dilated, pinpoint, or nonreactive.
Elevation of blood pressure with a widened pulse pressure.
Decreased pulse rate (may be increased initially).
Decreased respiratory rate (may be irregular).
c. Nursing Management.
Monitor vital signs closely.
Accurately assess and document neurological status.
(b) Evaluation of alterations of consciousness is crucial since
symptoms progress rapidly.
Maintain patent airway.
(a) Intubation and hyperventilation may be indicated to provide
adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced
(b) If patient is not intubated, position the patient on his side to
decrease the possibility of airway occlusion; use oral or nasopharyngeal airway, prn.