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❖Verbal response
❖Alertness
❖Motor response (posturing)
❖Respiratory status
❖Eye signs
❖Reflexes
❖Refer to Table 61-1
Adapted from Posner, J. B., Saper, C. B., Schiff, N. D., et al. (2007). Plum and
Posner’s diagnosis of stupor and coma (4th ed.). Oxford, UK: Oxford University
Press.
B. Mouth
True
❖Changes in LOC
❖Any change in condition
o Restlessness, confusion, increasing drowsiness,
increased respiratory effort, purposeless
movements
❖Pupillary changes and impaired ocular movements
❖Weakness in one extremity or one side
❖Headache: constant, increasing in intensity, or
aggravated by movement or straining
❖Brainstem herniation
❖Diabetes insipidus
❖SIADH
❖Increased ICP
❖Bleeding and hypovolemic shock
❖Fluid and electrolyte disturbances
❖Infection
❖CSF leak
❖Seizures
❖ Regulating temperature
o Cover patient appropriately
o Treat high temperature elevations vigorously; apply ice
bags, use hypothermia blanket, administer prescribed
acetaminophen
❖ Improving gas exchange
o Turn and reposition every 2 hours
o Encourage deep breathing and incentive spirometry
o Suction or encourage coughing cautiously as needed
(suctioning and coughing increases ICP)
o Humidification of oxygen may help loosen secretions
❖Sensory deprivation
o Periorbital edema may impair vision, announce
presence to avoid startling the patient; cool
compresses over eyes and elevation of HOB may
be used to reduce edema if not contraindicated
❖Enhancing self-image
o Encourage verbalization
o Encourage social interaction and social support
o Attention to grooming
o Cover head with turban and, later, a wig
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Nursing Interventions for the Patient
Undergoing Intracranial Surgery #4
D. Altered LOC
❖ Cerebrovascular disease
❖ Hypoxemia
❖ Fever (childhood)
❖ Head injury
❖ Hypertension
❖ Central nervous system infections
❖ Metabolic and toxic conditions
❖ Brain tumor
❖ Drug and alcohol withdrawal
❖ Allergies